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General NPI Number Information
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NPI Number | 1104081082
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Entity Type | Individual
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Provider Name | RUSSELL WILLIAM LAKE MD
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Gender | Male
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Dates
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Enumeration Date | 07/21/2008
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Last Update Date | 10/19/2021
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Provider Practice Location Address
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Address Line | 10055 FORD AVENUE SUITE 3A
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City | RICHMOND HILL
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State | GA
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Zip | 31324
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Country | US
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Telephone | 912-819-9601
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Fax | 912-819-9605
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Provider Business Mailing Address
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Address Line | 836 E. 65TH STREET SUITE 22
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City | SAVANNAH
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State | GA
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Zip | 31405
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Country | US
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Telephone | 912-819-7878
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Fax | 912-819-3320
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 31545
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 75198
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License Number State | GA
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