Provider Demographics
NPI:1578565735
Name:RISLEY, GEOFFREY LAKE (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:LAKE
Last Name:RISLEY
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:PO BOX 11982
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32524-1982
Mailing Address - Country:US
Mailing Address - Phone:850-479-1805
Mailing Address - Fax:850-479-9182
Practice Address - Street 1:5149 N 9TH AVE STE 120
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8734
Practice Address - Country:US
Practice Address - Phone:850-479-1805
Practice Address - Fax:850-479-1829
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME833482086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263422800Medicaid
P00023613OtherMEDICARE RAILROAD
FLG04474Medicare UPIN
FL06026YMedicare PIN