1023076874 NPI number — DR. LADD DANIEL LAKE M.D.

Table of content: DR. LADD DANIEL LAKE M.D. (NPI 1023076874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023076874 NPI number — DR. LADD DANIEL LAKE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAKE
Provider First Name:
LADD
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023076874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 362
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH PLATTE
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69103-0362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-477-7013
Provider Business Mailing Address Fax Number:
866-902-2445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 W LEOTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH PLATTE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69101-6525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-696-7491
Provider Business Practice Location Address Fax Number:
308-696-7432
Provider Enumeration Date:
05/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  22147 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 243897 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 0585794 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1603089 . This is a "SHARE ADVANTAGE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 605082700 . This is a "US DEPARTMENT OF LABOR" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 04192 . This is a "BC/BS OF NEBRASKA" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 10025186700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20050 . This is a "WELLMARK BC/BS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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