Provider Demographics
NPI:1477632982
Name:LAKE, CHARLES R (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901RAINBOW BLVD
Mailing Address - Street 2:4070 DELP
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160
Mailing Address - Country:US
Mailing Address - Phone:913-588-1325
Mailing Address - Fax:
Practice Address - Street 1:3901RAINBOW BLVD
Practice Address - Street 2:4070 DELP
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160
Practice Address - Country:US
Practice Address - Phone:913-588-1325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-244372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19717033OtherBC/BS
KSF68373Medicare UPIN
KS0615567AMedicare ID - Type Unspecified