Provider Demographics
NPI:1619014602
Name:GORMSEN, DAVID LAKE (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAKE
Last Name:GORMSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4189 SONGBIRD TRL
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-2572
Mailing Address - Country:US
Mailing Address - Phone:330-688-4160
Mailing Address - Fax:330-489-1487
Practice Address - Street 1:1320 MERCY DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2614
Practice Address - Country:US
Practice Address - Phone:330-489-1074
Practice Address - Fax:330-489-1487
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34002838207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34002838OtherMEDICAL LICENSE NUMBER