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General NPI Number Information
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NPI Number | 1255338513
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Entity Type | Individual
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Provider Name | RICHARD B LAKE O.D.
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Gender | Male
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Dates
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Enumeration Date | 07/01/2005
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Last Update Date | 08/21/2007
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Provider Practice Location Address
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Address Line | 6027 CYPRESS GARDENS BLVD
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City | WINTER HAVEN
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State | FL
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Zip | 33884-4115
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Country | US
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Telephone | 863-326-5824
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Fax |
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Provider Business Mailing Address
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Address Line | 685 SHANKLIN AVE
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City | BARTOW
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State | FL
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Zip | 33830-4335
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Country | US
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Telephone | 863-533-1363
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Fax |
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OP1036
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License Number State | FL
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