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General NPI Number Information
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NPI Number | 1619418563
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Entity Type | Organization
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Legal Business Name | LAKE ENDOCRINOLOGY AND DIABETES, PLLC
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Dates
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Enumeration Date | 03/12/2017
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Last Update Date | 05/02/2021
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Provider Practice Location Address
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Address Line | 13123 66TH ST
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City | LARGO
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State | FL
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Zip | 33773-1812
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Country | US
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Telephone | 727-477-1039
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Fax | 727-477-0498
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Provider Business Mailing Address
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Address Line | 13123 66TH ST
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City | LARGO
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State | FL
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Zip | 33773-1812
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Country | US
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Telephone | 727-477-1039
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Fax | 727-477-0498
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Authorized Official
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Title or Position | AMBR
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Name | BRIAN MATTHEW LAKE
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Credential | DO
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Telephone | 727-477-1039
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | OS9591
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number |
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License Number State |
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