Provider Demographics
NPI:1356379838
Name:LAKE, GORDON AVERY (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:AVERY
Last Name:LAKE
Suffix:
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 1:350 30TH STREET, SUITE 407
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-419-0230
Mailing Address - Fax:510-419-0273
Practice Address - Street 1:350 30TH STREET, SUITE 407
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-419-0230
Practice Address - Fax:510-419-0273
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22921207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G229210Medicaid
CA00G229210Medicare ID - Type Unspecified
CA00G229210Medicaid