Provider Demographics
NPI:1629270194
Name:LAKE, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:60 DOCTORS PARK LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-519-4949
Mailing Address - Fax:573-519-4665
Practice Address - Street 1:60 DOCTORS PARK LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-519-4949
Practice Address - Fax:573-519-4665
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2018-08-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO1083822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
G89564Medicare UPIN