Provider Demographics
NPI:1255338513
Name:LAKE, RICHARD B (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:B
Last Name:LAKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 SHANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-4335
Mailing Address - Country:US
Mailing Address - Phone:863-533-1363
Mailing Address - Fax:
Practice Address - Street 1:6027 CYPRESS GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-4115
Practice Address - Country:US
Practice Address - Phone:863-326-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP1036152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84109Medicare UPIN
FL19402Medicare ID - Type Unspecified