Provider Demographics
NPI:1306003835
Name:LAKE, SUSAN E (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
Last Name:LAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4550 N HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-1714
Mailing Address - Country:US
Mailing Address - Phone:614-428-8200
Mailing Address - Fax:614-428-9700
Practice Address - Street 1:4550 N HAMILTON RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-1714
Practice Address - Country:US
Practice Address - Phone:614-428-8200
Practice Address - Fax:614-428-9700
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34005856OtherSTATE LIC
OH0132412Medicaid
OH0778757Medicare PIN
OH0132412Medicaid