MEDICARE: DR. RICHARD B LAKE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OP1036	FL

General Provider Information

NPI Number	:	1255338513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD B LAKE O.D.

Provider Business Mailing Address
First Line	:	685 SHANKLIN AVE
Second Line	:
City	:	BARTOW
State	:	FL
Zip	:	33830-4335
Country	:	US
Telephone Number	:	863-533-1363
Fax Number	:

Provider Business Practice Location Address
First Line	:	6027 CYPRESS GARDENS BLVD
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-4115
Country	:	US
Telephone Number	:	863-326-5824
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	08/21/2007

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