Provider Demographics
NPI:1376561696
Name:LAKE, JON M (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:M
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0002
Mailing Address - Country:US
Mailing Address - Phone:517-784-0588
Mailing Address - Fax:517-784-3866
Practice Address - Street 1:400 HINCKLEY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-6125
Practice Address - Country:US
Practice Address - Phone:517-784-0588
Practice Address - Fax:517-784-3866
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-02-17
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Provider Licenses
StateLicense IDTaxonomies
MI4301068180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00420975OtherRR MEDICARE
MI80169124OtherRR MEDICARE
MI5187092-10Medicaid
MI0C86288007Medicare ID - Type Unspecified
MI80169124OtherRR MEDICARE
MI5187092-10Medicaid