Healthcare Provider Details

I. General information

NPI: 1184836447
Provider Name (Legal Business Name): ALLISON MARIE LAKE KOEPKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALLISON MARIE LAKE MD

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 BLUFFTON RD STE G
BLUFFTON SC
29910-6228
US

IV. Provider business mailing address

167 BLUFFTON RD STE G
BLUFFTON SC
29910-6228
US

V. Phone/Fax

Practice location:
  • Phone: 843-757-8663
  • Fax: 843-815-3849
Mailing address:
  • Phone: 843-757-8663
  • Fax: 843-815-3849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD89413
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: