Organization
LAKESIDE FAMILY MEDICINE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PAMELA E AHEARN MD (OWNER/PRESIDENT)
(580) 226-1010
Entity
Organization
Contact information
Practice address
21 N. MAIN STREET, KINGSTON, OK 73439-1798
(580) 226-1010
Mailing address
PO BOX 1798, KINGSTON, OK 73439-1798
(580) 226-1010
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
19862
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
PENDING
—
OK
Enumeration date
12/23/2009
Last updated
12/23/2009
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