Provider Demographics
NPI:1326006024
Name:LAKE, JEFFREY PRESTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PRESTON
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE 505
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE 505
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-645-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73315208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18801Medicare UPIN
WA73315AMedicare PIN