NPIMap

Organization Active NPI

South Lake Obstetrics & Gynecology, LLC

  • Obstetrics & Gynecology Physician
  • Clermont, FL
National Provider Identifier
1497754121
Registry record updated Mar 13, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X
License
OS8678 Issued in FL
Legal business name
SOUTH LAKE OBSTETRICS & GYNECOLOGY, LLC
Practice address
1900 Don Wickham Dr Ste 120
Clermont, FL 34711-1980
Phone
(352) 241-7050
Fax
(352) 241-7035
NPI assigned
Jul 15, 2005
Reactivated
Jan 28, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 13, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Matthew Stephan Casavant, DONPI 1003815671
Title
Owner
Phone
(321) 436-8371

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Obstetrics & Gynecology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207V00000X OS8678 FL Primary

Addresses

Primary practice location

1900 Don Wickham Dr Ste 120
Clermont, FL 34711-1980

Mailing address

1900 Don Wickham Dr Ste 120
Clermont, FL 34711-1980
Phone (352) 241-7050

Other identifiers 1

IdentifierTypeStateIssuer
264093700MedicaidFL

Other names 1

  • SOUTH LAKE OB/GYN AND ADVANCED SURGERY Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040506001236 FL Part B Supplier - Clinic/Group Practice 9638168693 Receives reassigned benefits from 7 practitioners
Practice locations: Clermont, FL

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D0999175South Lake OB-GYN1900 Don Wickham Dr Suite 120, Clermont, FL 34711Provider-performed microscopyMar 13, 2027

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121385600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710288000000",
    "number": "1497754121",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1900 DON WICKHAM DR STE 120",
            "city": "CLERMONT",
            "state": "FL",
            "postal_code": "347111980",
            "telephone_number": "352-241-7050",
            "fax_number": "352-241-7035"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1900 DON WICKHAM DR STE 120",
            "city": "CLERMONT",
            "state": "FL",
            "postal_code": "347111980",
            "telephone_number": "352-241-7050",
            "fax_number": "352-241-7035"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH LAKE OBSTETRICS & GYNECOLOGY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-15",
        "last_updated": "2024-03-13",
        "certification_date": "2024-03-13",
        "deactivation_date": "2005-07-18",
        "reactivation_date": "2008-01-28",
        "status": "A",
        "authorized_official_last_name": "CASAVANT",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_middle_name": "STEPHAN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "321-436-8371",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": "FL",
            "license": "OS8678",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "264093700",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SOUTH LAKE OB/GYN AND ADVANCED SURGERY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Clermont, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 13, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.