Healthcare Provider Details

I. General information

NPI: 1821224809
Provider Name (Legal Business Name): ANDREW N LAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2009
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 LIMESTONE OVERLOOK
GAINESVILLE GA
30501-7443
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-8109
  • Fax: 770-536-3203
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number072389
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: