Healthcare Provider Details

I. General information

NPI: 1407382898
Provider Name (Legal Business Name): ADAM JOHN LAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 BROWNING PL STE 201
RALEIGH NC
27609-6530
US

IV. Provider business mailing address

3900 BROWNING PL STE 201
RALEIGH NC
27609-6530
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-7125
  • Fax: 919-781-9952
Mailing address:
  • Phone: 919-787-7125
  • Fax: 919-781-9952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number228550
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2018-02470
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: