Provider Demographics
NPI:1043585169
Name:LAKE WOMEN FOR WOMEN OB/GYN,LLC
Entity type:Organization
Organization Name:LAKE WOMEN FOR WOMEN OB/GYN,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-589-6005
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-0780
Mailing Address - Country:US
Mailing Address - Phone:352-589-6005
Mailing Address - Fax:352-484-0189
Practice Address - Street 1:2 N EUSTIS ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-3408
Practice Address - Country:US
Practice Address - Phone:352-589-6005
Practice Address - Fax:352-484-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty