Provider Demographics
NPI:1710919139
Name:LAKE, ERIC J (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:J
Last Name:LAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:525 W CHESTER PIKE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4500
Mailing Address - Country:US
Mailing Address - Phone:610-789-7767
Mailing Address - Fax:610-789-7768
Practice Address - Street 1:525 W CHESTER PIKE
Practice Address - Street 2:SUITE 203
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4500
Practice Address - Country:US
Practice Address - Phone:610-789-7767
Practice Address - Fax:610-789-7768
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS012275207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016353100001Medicaid