Provider Demographics
NPI:1184790966
Name:LAKE, LEANNE (MD)
Entity type:Individual
Prefix:DR
First Name:LEANNE
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7695 S 175 W
Mailing Address - Street 2:P. O. BOX 398
Mailing Address - City:MILROY
Mailing Address - State:IN
Mailing Address - Zip Code:46156-9668
Mailing Address - Country:US
Mailing Address - Phone:765-629-2224
Mailing Address - Fax:765-629-2856
Practice Address - Street 1:7695 S 175 W
Practice Address - Street 2:
Practice Address - City:MILROY
Practice Address - State:IN
Practice Address - Zip Code:46156-9668
Practice Address - Country:US
Practice Address - Phone:765-629-2224
Practice Address - Fax:765-629-2856
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000088990OtherBCBS
IN710900Medicare ID - Type Unspecified
INE05062Medicare UPIN