Healthcare Provider Details

I. General information

NPI: 1740360619
Provider Name (Legal Business Name): JOHN RICHARD LAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF MINNESOTA PHYSICIANS 516 DELAWARE STREET SE, CLINIC 2A
MINNEAPOLIS MN
55454-1478
US

IV. Provider business mailing address

UNIVERSITY OF MINNESOTA PHYSICIANS 420 DELAWARE ST SE, MMC 36
MINNEAPOLIS MN
55455
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-6100
  • Fax:
Mailing address:
  • Phone: 612-626-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number40739
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: