Provider Demographics
NPI:1740201789
Name:JAMESON, LAKE H (MD)
Entity Type:Individual
Prefix:
First Name:LAKE
Middle Name:H
Last Name:JAMESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29634-4054
Mailing Address - Country:US
Mailing Address - Phone:864-656-2233
Mailing Address - Fax:864-656-0760
Practice Address - Street 1:735 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29634-4054
Practice Address - Country:US
Practice Address - Phone:864-656-2233
Practice Address - Fax:864-656-0760
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11994207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC119945Medicaid
D18268Medicare UPIN
4542Medicare PIN