NPIMap

Organization Active NPI

Lakeside Dermatology , PA

  • Dermatology Physician
  • Cornelius, NC
National Provider Identifier
1619973054
Registry record updated Mar 23, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
9400198 Issued in NC
Legal business name
LAKESIDE DERMATOLOGY , PA
Practice address
19900 W Catawba Ave
Suite B
Cornelius, NC 28031-4032
Phone
(704) 892-4878
Fax
(704) 892-7453
NPI assigned
Jun 21, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 23, 2011

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

Authorized official

Name
Nancy J Astle, MD
Title
President/Physician
Phone
(704) 892-4878

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X 9400198 NC Primary

Addresses

Primary practice location

19900 W Catawba Ave
Suite B
Cornelius, NC 28031-4032

Mailing address

19900 W Catawba Ave
Ste B
Cornelius, NC 28031-4032
Phone (704) 892-4878

Other identifiers 3

IdentifierTypeStateIssuer
01056OtherNCBCBS
CA0767OtherRAILROAD MEDICARE
E82914OtherUPIN

National Provider Directory

National Provider Directory

Locations

19900 W Catawba Ave
#B
Cornelius, NC 28031
Phone (704) 892-4878

Practitioners & affiliated clinicians

Practitioners 11

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": "1119312000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1300838400000",
    "number": "1619973054",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19900 W CATAWBA AVE",
            "address_2": "STE B",
            "city": "CORNELIUS",
            "state": "NC",
            "postal_code": "280314032",
            "telephone_number": "704-892-4878",
            "fax_number": "704-892-7453"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19900 W CATAWBA AVE",
            "address_2": "SUITE B",
            "city": "CORNELIUS",
            "state": "NC",
            "postal_code": "280314032",
            "telephone_number": "704-892-4878",
            "fax_number": "704-892-7453"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESIDE DERMATOLOGY , PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-21",
        "last_updated": "2011-03-23",
        "status": "A",
        "authorized_official_last_name": "ASTLE",
        "authorized_official_first_name": "NANCY",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT/PHYSICIAN",
        "authorized_official_telephone_number": "704-892-4878",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": "NC",
            "license": "9400198",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "01056",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CA0767",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UPIN",
            "identifier": "E82914",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Cornelius, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 23, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.