Provider Demographics
NPI:1962456822
Name:LAKE, EDWARD C JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:LAKE
Suffix:JR
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 1:235 E CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1783
Mailing Address - Country:US
Mailing Address - Phone:517-279-8465
Mailing Address - Fax:517-279-8665
Practice Address - Street 1:235 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1783
Practice Address - Country:US
Practice Address - Phone:517-279-8465
Practice Address - Fax:517-279-8665
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301043994207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1562337Medicaid
B49518Medicare UPIN
MI1562337Medicaid