Provider Demographics
NPI:1003952375
Name:LAKE, DIANAH THELMA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANAH
Middle Name:THELMA
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DIANAH
Other - Middle Name:THELMA
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8 LEO TER
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4414
Mailing Address - Country:US
Mailing Address - Phone:917-334-2381
Mailing Address - Fax:973-338-1041
Practice Address - Street 1:1400 PELHAM PKWY S
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1138
Practice Address - Country:US
Practice Address - Phone:718-918-5820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08177800207P00000X
MEMD21481207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine