Healthcare Provider Details

I. General information

NPI: 1710919139
Provider Name (Legal Business Name): ERIC J LAKE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W CHESTER PIKE SUITE 203
HAVERTOWN PA
19083-4500
US

IV. Provider business mailing address

525 W CHESTER PIKE SUITE 203
HAVERTOWN PA
19083-4500
US

V. Phone/Fax

Practice location:
  • Phone: 610-789-7767
  • Fax: 610-789-7768
Mailing address:
  • Phone: 610-789-7767
  • Fax: 610-789-7768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS012275
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: