Provider Demographics
NPI:1952405318
Name:LAKE, MARLYN A (MD)
Entity Type:Individual
Prefix:
First Name:MARLYN
Middle Name:A
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARYLN
Other - Middle Name:A
Other - Last Name:PATTERSON-LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:380 HOSPITAL DR STE 370
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-8010
Practice Address - Country:US
Practice Address - Phone:478-219-7735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME764902084N0400X
GA846462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNT772OtherFL HF MEDICARE
FL257303200Medicaid
FL44751OtherBCBS
FL257303200Medicaid
FL44751OtherBCBS
FLK3655Medicare ID - Type Unspecified