Provider Demographics
NPI:1679866305
Name:LAKE, KATRINA (MD)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:
Other - Last Name:BLANCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35318 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1353
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:20201 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1010
Practice Address - Country:US
Practice Address - Phone:708-679-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036141229207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program