Provider Demographics
NPI:1093947111
Name:LAKE PODIATRY, P.A.
Entity Type:Organization
Organization Name:LAKE PODIATRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:603-536-4563
Mailing Address - Street 1:144 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-1240
Mailing Address - Country:US
Mailing Address - Phone:603-536-4563
Mailing Address - Fax:603-536-1056
Practice Address - Street 1:144 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1240
Practice Address - Country:US
Practice Address - Phone:603-536-4563
Practice Address - Fax:603-536-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty