Provider Demographics
NPI:1104203702
Name:LAKE, JULIA CAROLINE WINGATE (MD)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:CAROLINE WINGATE
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:CAROLINE WINGATE
Other - Last Name:MCNEIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:DHMC DEPT OF INTERNAL MEDICINE
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756
Practice Address - Country:US
Practice Address - Phone:603-653-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-03
Last Update Date:2019-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NH20155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program