Healthcare Provider Details

I. General information

NPI: 1356379838
Provider Name (Legal Business Name): GORDON AVERY LAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 30TH STREET, SUITE 407
OAKLAND CA
94609
US

IV. Provider business mailing address

350 30TH STREET, SUITE 407
OAKLAND CA
94609
US

V. Phone/Fax

Practice location:
  • Phone: 510-419-0230
  • Fax: 510-419-0273
Mailing address:
  • Phone: 510-419-0230
  • Fax: 510-419-0273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG22921
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: