Healthcare Provider Details

I. General information

NPI: 1619418563
Provider Name (Legal Business Name): LAKE ENDOCRINOLOGY AND DIABETES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2017
Last Update Date: 05/02/2021
Certification Date: 05/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 66TH ST
LARGO FL
33773-1812
US

IV. Provider business mailing address

13123 66TH ST
LARGO FL
33773-1812
US

V. Phone/Fax

Practice location:
  • Phone: 727-477-1039
  • Fax: 727-477-0498
Mailing address:
  • Phone: 727-477-1039
  • Fax: 727-477-0498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberOS9591
License Number StateFL

VIII. Authorized Official

Name: BRIAN MATTHEW LAKE
Title or Position: AMBR
Credential: DO
Phone: 727-477-1039