Provider Demographics
NPI:1295887040
Name:LAKE, BRIAN MATTHEW (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MATTHEW
Last Name:LAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13123 66TH ST
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-1812
Mailing Address - Country:US
Mailing Address - Phone:727-477-1039
Mailing Address - Fax:727-477-0498
Practice Address - Street 1:13123 66TH ST
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-1812
Practice Address - Country:US
Practice Address - Phone:727-477-1039
Practice Address - Fax:727-477-0498
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9591207R00000X, 207RE0101X
SC1056207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106202000Medicaid
FLP00756358OtherRAILROAD MEDICARE PIN
FL001214800Medicaid