Provider Demographics
NPI:1003881277
Name:LAKE, THOMAS ROSSER III (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROSSER
Last Name:LAKE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 MONMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755-1515
Mailing Address - Country:US
Mailing Address - Phone:732-531-5445
Mailing Address - Fax:732-531-1776
Practice Address - Street 1:255 MONMOUTH RD
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-1515
Practice Address - Country:US
Practice Address - Phone:732-531-5445
Practice Address - Fax:732-531-1776
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07084700208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ637073Medicare ID - Type Unspecified
NJH59701Medicare UPIN