Provider Demographics
NPI:1912062480
Name:LAKE, NATALIE J (MD)
Entity Type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:J
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 5204
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0603
Mailing Address - Country:US
Mailing Address - Phone:623-889-3477
Mailing Address - Fax:623-889-3478
Practice Address - Street 1:750 N ESTRELLA PKWY STE 40
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9279
Practice Address - Country:US
Practice Address - Phone:623-889-3477
Practice Address - Fax:623-889-3478
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC134094207Q00000X
MDD73655207Q00000X
AZ59280207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
606897000OtherDEPT OF LABOR
K6400010OtherCAREFIRST
MD441188900Medicaid
953BAN97701301OtherCAREFIRST MARYLAND
P01208435OtherRR MEDICARE
P01208435OtherRR MEDICARE