Provider Demographics
NPI:1578904892
Name:LAKE, EDEN LOUISE PAPPO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDEN
Middle Name:LOUISE PAPPO
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:EDEN
Other - Middle Name:LOUISE
Other - Last Name:PAPPO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDEN PAPPO
Mailing Address - Street 1:321 N LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-5622
Mailing Address - Country:US
Mailing Address - Phone:708-485-1271
Mailing Address - Fax:
Practice Address - Street 1:321 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-5622
Practice Address - Country:US
Practice Address - Phone:708-485-1271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125062828207R00000X
IL036.143392207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILFL683494OtherDEA