Provider Demographics
NPI:1649234378
Name:LAKE, BETHANY T (MD)
Entity Type:Individual
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First Name:BETHANY
Middle Name:T
Last Name:LAKE
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Gender:F
Credentials:MD
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Mailing Address - Street 1:1 MEDICAL CENTER DRIVE
Mailing Address - Street 2:PO BOX 626
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005
Mailing Address - Country:US
Mailing Address - Phone:207-282-9080
Mailing Address - Fax:207-282-9180
Practice Address - Street 1:10 GOODALL DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:E. WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04030
Practice Address - Country:US
Practice Address - Phone:207-490-7970
Practice Address - Fax:207-282-9128
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2014-12-18
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Provider Licenses
StateLicense IDTaxonomies
ME015660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME247150099Medicaid
ME247150099Medicaid
MEH54531Medicare UPIN