Provider Demographics
NPI:1649258468
Name:LAKE, TIFFINI JAYE (MD)
Entity type:Individual
Prefix:DR
First Name:TIFFINI
Middle Name:JAYE
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:PO BOX 1063
Mailing Address - Street 2:FLETCHER ALLEN HEALTH CARE
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05402-1063
Mailing Address - Country:US
Mailing Address - Phone:802-847-2415
Mailing Address - Fax:802-847-5324
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:DEPT OF ANESTHESIOLOGY
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2415
Practice Address - Fax:802-847-5324
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Not Answered207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011631Medicaid
I10709Medicare UPIN
VT1011631Medicaid