Provider Demographics
NPI:1568497238
Name:LAKE, JOHN RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSSELL
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BLDG 3 SUITE 256
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-462-3131
Mailing Address - Fax:619-462-1731
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BLDG 3 SUITE 256
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-462-3131
Practice Address - Fax:619-462-1731
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG14553207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARZZZ72232ZMedicaid
ARZZZ72232ZMedicaid
CAW1053Medicare ID - Type UnspecifiedMEDICARE