Provider Demographics
NPI:1689898447
Name:LAKE DERMATOLOGY INC.
Entity Type:Organization
Organization Name:LAKE DERMATOLOGY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-538-3508
Mailing Address - Street 1:15 EXECUTIVE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-3833
Mailing Address - Country:US
Mailing Address - Phone:765-838-3428
Mailing Address - Fax:765-838-3440
Practice Address - Street 1:15 EXECUTIVE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-3833
Practice Address - Country:US
Practice Address - Phone:765-838-3428
Practice Address - Fax:765-838-3440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055166A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN252950Medicare PIN
IN252950AMedicare PIN
INH16853Medicare UPIN