MEDICARE: GENE (GERALD) EUGENE LAKE M.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	2084P0800X	Psychiatry Physician	G20748	AR

General Provider Information

NPI Number	:	1871718528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENE (GERALD) EUGENE LAKE M.D.

Provider Business Mailing Address
First Line	:	230 W LAUREL ST
Second Line	:	UNTI 703
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1461
Country	:	US
Telephone Number	:	619-595-1564
Fax Number	:	858-720-8285

Provider Business Practice Location Address
First Line	:	230 W LAUREL ST
Second Line	:	UNIT 703
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1461
Country	:	US
Telephone Number	:	619-595-1564
Fax Number	:	858-720-8285

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

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	07/08/2007

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