Provider Demographics
NPI:1326084732
Name:LAKE, JOSEPHINE H (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPHINE
Middle Name:H
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JOSEPHINE
Other - Middle Name:H
Other - Last Name:HOOTEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:
Practice Address - Street 1:16525 HOLLY CREST LN STE 150
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-4911
Practice Address - Country:US
Practice Address - Phone:704-384-8720
Practice Address - Fax:704-384-8747
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800943207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891180CMedicaid
NCG84369Medicare UPIN
NC891180CMedicaid