Provider Demographics
NPI:1740360619
Name:LAKE, JOHN RICHARD (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE ST SE, MMC 36
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-6100
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:516 DELAWARE STREET SE, CLINIC 2A
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1478
Practice Address - Country:US
Practice Address - Phone:612-626-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40739207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN124409OtherUCARE
MN29-00011OtherMEDICA-PRIMARY
784417OtherARAZ
IA0506741Medicaid
MN114843OtherFAIRVIEW
MN03G121LAOtherBCBS
MN1017135OtherPREFERRED ONE
MN480019200Medicaid
MNHP28838OtherHEALTH PARTNERS
WI32420100Medicaid
MN2900020OtherMEDICA-CHOICE
MN29-00011OtherMEDICA-PRIMARY
MN114843OtherFAIRVIEW
MN1017135OtherPREFERRED ONE
WI32420100Medicaid