Healthcare Provider Details

I. General information

NPI: 1194777136
Provider Name (Legal Business Name): GEORGE BLAINE LAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WILLOW PLZ 201
VISALIA CA
93291-6206
US

IV. Provider business mailing address

100 WILLOW PLZ 201
VISALIA CA
93291-6206
US

V. Phone/Fax

Practice location:
  • Phone: 559-627-9284
  • Fax: 559-713-0965
Mailing address:
  • Phone: 559-627-9284
  • Fax: 559-713-0965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG86776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: