Healthcare Provider Details

I. General information

NPI: 1639487002
Provider Name (Legal Business Name): JEFFREY P. LAKE, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16311 VENTURA BLVD SUITE 505
ENCINO CA
91436-2124
US

IV. Provider business mailing address

16311 VENTURA BLVD SUITE 505
ENCINO CA
91436-2124
US

V. Phone/Fax

Practice location:
  • Phone: 818-387-8725
  • Fax:
Mailing address:
  • Phone: 818-387-8725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberA73315
License Number StateCA

VIII. Authorized Official

Name: JEFFREY LAKE
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 818-387-8725