Provider Demographics
NPI:1619418563
Name:LAKE ENDOCRINOLOGY AND DIABETES, PLLC
Entity Type:Organization
Organization Name:LAKE ENDOCRINOLOGY AND DIABETES, PLLC
Other - Org Name:LAKE ENDOCRINOLOGY CONSULTING, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-477-1039
Mailing Address - Street 1:13123 66TH ST
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-1812
Mailing Address - Country:US
Mailing Address - Phone:727-477-1039
Mailing Address - Fax:727-477-0498
Practice Address - Street 1:13123 66TH ST
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-1812
Practice Address - Country:US
Practice Address - Phone:727-477-1039
Practice Address - Fax:727-477-0498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-12
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RE0101X
FLOS9591261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty