Provider Demographics
NPI:1649245101
Name:LAKE, MARJORIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:E
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3209 W SMITH VALLEY RD
Mailing Address - Street 2:STE. 251
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-8495
Mailing Address - Country:US
Mailing Address - Phone:317-893-2364
Mailing Address - Fax:317-851-8066
Practice Address - Street 1:3209 W SMITH VALLEY RD
Practice Address - Street 2:STE. 251
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-8495
Practice Address - Country:US
Practice Address - Phone:317-893-2364
Practice Address - Fax:317-851-8066
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2013-08-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01024834A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100333590Medicaid
INC24284Medicare UPIN