Organization
LAKESIDE FAMILY MEDICINE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PAMELA AHEARN MD (OWNER)
(580) 564-0200
Entity
Organization
Contact information
Practice address
714 HWY 70 E, KINGSTON, OK 73439
(580) 564-0200
Mailing address
PO BOX 1798, KINGSTON, OK 73439-1798
(580) 564-0200
(580) 564-0201
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200272990A
—
OK
Enumeration date
10/07/2014
Last updated
10/07/2014
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