Provider Demographics
NPI:1558445536
Name:LAKES, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:LAKES
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 1:249 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2751
Mailing Address - Country:US
Mailing Address - Phone:415-454-8611
Mailing Address - Fax:
Practice Address - Street 1:249 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2751
Practice Address - Country:US
Practice Address - Phone:415-444-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22953207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G229530Medicaid
CA00G229530Medicaid
00G229530Medicare ID - Type Unspecified