Provider Demographics
NPI:1205051430
Name:LAKE, JASON EDWARD (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:EDWARD
Last Name:LAKE
Suffix:
Gender:
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:PO BOX 80217
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0217
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:480-418-3323
Practice Address - Street 1:2940 E BANNER GATEWAY DR STE 200-250
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2168
Practice Address - Country:US
Practice Address - Phone:480-964-2908
Practice Address - Fax:480-833-2136
Is Sole Proprietor?:No
Enumeration Date:2007-04-14
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35. 093195207X00000X
AZ42724207X00000X, 207XX0004X
MS19568207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3Z5372OtherHEALTHNET
AZP00889049Medicare PIN
AZ3Z5372OtherHEALTHNET