Provider Demographics
NPI:1780637355
Name:LAKEW, ELIAS (MD)
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:
Last Name:LAKEW
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 1:15905 WILLIS WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:MD
Mailing Address - Zip Code:21797-7521
Mailing Address - Country:US
Mailing Address - Phone:410-489-2821
Mailing Address - Fax:
Practice Address - Street 1:7300 VAN DUSEN RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-9266
Practice Address - Country:US
Practice Address - Phone:301-725-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053055207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413046400Medicaid
MDP00430518OtherRAILROAD
MD089000601Medicaid
MD089000601Medicaid
MD489PR150Medicare PIN
MDP00430518OtherRAILROAD
MDR150Medicare PIN
MD489PMedicare PIN
MD161MM134Medicare PIN