# LAKE PODIATRY, PC

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

## Provider details

- **NPI number:** 1063449346
- **Authorized official:** RAZIUDDIN AHMED DPM (PRESIDENT & CEO)
- **Authorized official phone:** (818) 518-6768

## Contact information

- **Practice address:** 10570 BLUE STAR M HWY, SOUTH HAVEN, MI 49090-8923
- **Practice address phone:** (269) 978-3385
- **Practice address fax:** (269) 978-2711
- **Mailing address:** 10570 BLUE STAR M HWY, SOUTH HAVEN, MI 49090-8923
- **Mailing address phone:** (269) 978-3385
- **Mailing address fax:** (269) 978-2711

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 213ES0103X | Foot & Ankle Surgery Podiatrist | 5901002029 | MI | Yes |

## Other

- **Enumeration date:** 06/26/2006
- **Last updated:** 05/29/2009