NPIMap

Organization Active NPI

Lake Pediatrics P. a.

  • Rural Health Clinic/Center
  • Mount Dora, FL
National Provider Identifier
1942367370
Registry record updated Nov 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
LAKE PEDIATRICS P. A.
Doing business as
Lake Pediatrics, P.A.
Practice address
4880 N Highway 19a Ste 200
Mount Dora, FL 32757-2018
Phone
(352) 589-8111
Fax
(352) 589-8111
NPI assigned
Jan 3, 2007
Last updated
Nov 12, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 12, 2025

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

Authorized official

Name
Donna Lynn Nettles
Title
Billing Manager
Phone
(523) 638-4997

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

4880 N Highway 19a Ste 200
Mount Dora, FL 32757-2018

Mailing address

4880 N Hwy 19 a
Mt Dora, FL 32757-2018
Phone (352) 589-8111

Other identifiers 1

IdentifierTypeStateIssuer
126977000MedicaidFL

Other names 1

  • Lake Pediatrics, P.A. Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20041130000052 FL Part A Provider - Rural Health Clinic 1557326709 Practice locations: Mount Dora, FL
O20201209000113 FL Part B Supplier - Clinic/Group Practice 1557326709 Receives reassigned benefits from 2 practitioners
Practice locations: Mount Dora, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1942367370. Details of each certification follow.

Rural health clinic certification: CCN 108915

Legal name
LAKE PEDIATRICS P. A
Doing business as
LAKE PEDIATRICS P. A
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 23, 1999
Last certification
Feb 15, 2024
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Jan 1, 1996 in FL
Enrollment address
4880 N Highway 19a
Ste 200
Mount Dora, FL 32757-2018

National Provider Directory

National Provider Directory
Tax ID family
Lake Pediatrics P a2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4880 N Highway 19A
Ste 200
Mount Dora, FL 32757
Phone (352) 589-8111

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Anna Walls Individual 5% Or Greater Direct Ownership InterestOwner Apr 29, 2025 50%
Donna Nettles Individual 5% Or Greater Direct Ownership InterestOwner Apr 26, 2025 50%
W-2 Managing EmployeeBilling Manager Aug 7, 2013
Liliane Kovacs Lesmes Individual W-2 Managing EmployeeMD; Jun 3, 2025

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1167782400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1762905600000",
    "number": "1942367370",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4880 N HWY 19 A",
            "city": "MT DORA",
            "state": "FL",
            "postal_code": "327572018",
            "telephone_number": "352-589-8111",
            "fax_number": "352-589-8495"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4880 N HIGHWAY 19A STE 200",
            "city": "MOUNT DORA",
            "state": "FL",
            "postal_code": "327572018",
            "telephone_number": "352-589-8111",
            "fax_number": "352-589-8111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE PEDIATRICS P. A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-03",
        "last_updated": "2025-11-12",
        "certification_date": "2025-11-12",
        "status": "A",
        "authorized_official_last_name": "NETTLES",
        "authorized_official_first_name": "DONNA",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "523-638-4997"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "126977000",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Pediatrics, P.A.",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mount Dora, FL

Sources for this page

Verify at the official NPI Registry.