Healthcare Provider Details

I. General information

NPI: 1114909371
Provider Name (Legal Business Name): JEREMY M LAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 SE 7TH AVE
HILLSBORO OR
97123
US

IV. Provider business mailing address

232 SE 7TH AVE
HILLSBORO OR
97123
US

V. Phone/Fax

Practice location:
  • Phone: 503-640-1614
  • Fax: 503-681-0925
Mailing address:
  • Phone: 503-640-1614
  • Fax: 503-681-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD24736
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: