Provider Demographics
NPI:1982872784
Name:LAKE, JEFFREY THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:THOMAS
Last Name:LAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 MAIN ST
Mailing Address - Street 2:ST. JOSEPH'S REGIONAL MEDICAL CENTER
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503-2621
Mailing Address - Country:US
Mailing Address - Phone:973-754-2323
Mailing Address - Fax:973-977-9455
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:ST. JOSEPH'S REGIONAL MEDICAL CENTER
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2621
Practice Address - Country:US
Practice Address - Phone:973-754-2323
Practice Address - Fax:973-977-9455
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB08901500207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program