Provider Demographics
NPI:1720603392
Name:LAKE, RUSSELL STEVEN (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:STEVEN
Last Name:LAKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 HIGHLINE DR
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-5344
Mailing Address - Country:US
Mailing Address - Phone:509-886-0924
Mailing Address - Fax:
Practice Address - Street 1:375 HIGHLINE DR
Practice Address - Street 2:
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-5344
Practice Address - Country:US
Practice Address - Phone:509-886-0924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61042825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist