# LAKESIDE PEDIATRIC & ADOLESCENT MEDICINE, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1003975087
- **Authorized official:** DIANA R VANHOOK (OFFICE MANAGER)
- **Authorized official phone:** (208) 292-5437

## Contact information

- **Practice address:** 980 W IRONWOOD DR, STE 302, COEUR D'ALENE, ID 83814-2601
- **Practice address phone:** (208) 292-5437
- **Practice address fax:** (208) 292-5441
- **Mailing address:** 980 W IRONWOOD DR, STE 302, COEUR D'ALENE, ID 83814-2601
- **Mailing address phone:** (208) 292-5437
- **Mailing address fax:** (208) 292-5441

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | NULL | Yes |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 12/06/2006
- **Last updated:** 07/12/2012