Healthcare Provider Details

I. General information

NPI: 1740923606
Provider Name (Legal Business Name): LAKE JOSEPH WALSH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MASSACHUSETTS AVE STE 5B CROSSTOWN BLDG
BOSTON MA
02118
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5951
  • Fax: 617-414-9201
Mailing address:
  • Phone: 617-414-5951
  • Fax: 617-414-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1028762
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: