Provider Demographics
NPI:1114909371
Name:LAKE, JEREMY M (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:LAKE
Suffix:
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 1:232 SE 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123
Mailing Address - Country:US
Mailing Address - Phone:503-640-1614
Mailing Address - Fax:503-681-0925
Practice Address - Street 1:232 SE 7TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123
Practice Address - Country:US
Practice Address - Phone:503-640-1614
Practice Address - Fax:503-681-0925
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24736207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR183065Medicaid
I17329Medicare UPIN
OR132046Medicare PIN