Provider Demographics
NPI:1285687210
Name:LAKE, SUSAN (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E RUSSELL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-9605
Mailing Address - Country:US
Mailing Address - Phone:660-747-2020
Mailing Address - Fax:660-747-0574
Practice Address - Street 1:601 E RUSSELL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-9605
Practice Address - Country:US
Practice Address - Phone:660-747-2020
Practice Address - Fax:660-747-0574
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03457152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU75402Medicare UPIN