Provider Demographics
NPI:1295857043
Name:LAKE, HEATHER M (DO)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:LAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 FRANTZ RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 E STATE ST
Practice Address - Street 2:SUITE 620
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4354
Practice Address - Country:US
Practice Address - Phone:614-566-9380
Practice Address - Fax:614-566-8175
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34009625207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2966714Medicaid
OH4267061Medicare PIN