Provider Demographics
NPI:1255865952
Name:LAKE, STEPHANIE ANN (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:LAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:A
Other - Last Name:WEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-3000
Mailing Address - Fax:
Practice Address - Street 1:1816 HARVARD BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-4543
Practice Address - Country:US
Practice Address - Phone:937-641-4000
Practice Address - Fax:937-641-4500
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013785208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0226309Medicaid