1326084732 NPI number — DR. JOSEPHINE H LAKE MD

Table of content: DR. JOSEPHINE H LAKE MD (NPI 1326084732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326084732 NPI number — DR. JOSEPHINE H LAKE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAKE
Provider First Name:
JOSEPHINE
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOOTEN
Provider Other First Name:
JOSEPHINE
Provider Other Middle Name:
H
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1326084732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
LAKE INTERNAL MEDICINE AND PEDIATRICS, PLLC
Provider Second Line Business Mailing Address:
13801 REESE BLVD WEST SUITE 150
Provider Business Mailing Address City Name:
HUNTERSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-274-8006
Provider Business Mailing Address Fax Number:
704-997-3058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13801 REESE BLVD WEST
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
HUNTERSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-274-8006
Provider Business Practice Location Address Fax Number:
704-997-3058
Provider Enumeration Date:
06/22/2006

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: 207R00000X , with the licence number:  9800943 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 9800943 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 891180C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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