Provider Demographics
NPI:1275719627
Name:LAKE INTERNAL MED SPECIAL
Entity Type:Organization
Organization Name:LAKE INTERNAL MED SPECIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:M
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-348-6700
Mailing Address - Street 1:980 EXECUTIVE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3495
Mailing Address - Country:US
Mailing Address - Phone:573-348-6700
Mailing Address - Fax:573-348-3310
Practice Address - Street 1:980 EXECUTIVE DR
Practice Address - Street 2:SUITE D
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3495
Practice Address - Country:US
Practice Address - Phone:573-348-6700
Practice Address - Fax:573-348-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORIE24261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty