Provider Demographics
NPI:1558343103
Name:LAKE, KATHLEEN A (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:LAKE
Suffix:
Gender:F
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:PO BOX 19658
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9658
Mailing Address - Country:US
Mailing Address - Phone:217-545-4238
Mailing Address - Fax:217-545-2303
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-545-4238
Practice Address - Fax:217-545-2303
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-086125208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-086125Medicaid
F57524Medicare UPIN
ILL60064Medicare ID - Type Unspecified