# LAKESIDE MEDICAL PLLC

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

## Provider details

- **NPI number:** 1376210500
- **Authorized official:** DR. GAYLON E CRAWFORD D.O. (PHYSICIAN)
- **Authorized official phone:** (928) 367-6828

## Contact information

- **Practice address:** 300 W WHITE MOUNTAIN BLVD \#C, LAKESIDE, AZ 85929-7014
- **Practice address phone:** (928) 367-6828
- **Practice address fax:** (928) 367-4037
- **Mailing address:** 300 W WHITE MOUNTAIN BLVD \#C, LAKESIDE, AZ 85929-7014
- **Mailing address phone:** (928) 367-6828
- **Mailing address fax:** (928) 367-4037

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 08/25/2021
- **Last updated:** 03/16/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 368333 | — | AZ |