Healthcare Provider Details

I. General information

NPI: 1275100273
Provider Name (Legal Business Name): KATHERINE ELEANOR LAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6110
US

IV. Provider business mailing address

8200 WALNUT HILL LN
DALLAS TX
75231-4402
US

V. Phone/Fax

Practice location:
  • Phone: 214-998-2004
  • Fax:
Mailing address:
  • Phone: 214-345-6789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number3019995
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: