Provider Demographics
NPI:1104848423
Name:LAKE, MARK ADRIAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ADRIAN
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 EXECUTIVE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-3833
Mailing Address - Country:US
Mailing Address - Phone:765-838-3428
Mailing Address - Fax:765-838-3440
Practice Address - Street 1:15 EXECUTIVE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-3833
Practice Address - Country:US
Practice Address - Phone:765-838-3428
Practice Address - Fax:765-838-3440
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01055166207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INH16853Medicare UPIN
IN252950Medicare PIN
IN252950AMedicare PIN