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General NPI Number Information
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NPI Number | 1689898447
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Entity Type | Organization
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Legal Business Name | LAKE DERMATOLOGY INC.
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 11/13/2008
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Provider Practice Location Address
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Address Line | 15 EXECUTIVE DR SUITE 4
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City | LAFAYETTE
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State | IN
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Zip | 47905-3833
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Country | US
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Telephone | 765-838-3428
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Fax | 765-838-3440
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Provider Business Mailing Address
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Address Line | 15 EXECUTIVE DR SUITE 4
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City | LAFAYETTE
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State | IN
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Zip | 47905-3833
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Country | US
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Telephone | 765-838-3428
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Fax | 765-838-3440
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARK ADRIAN LAKE
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Credential | M.D.
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Telephone | 765-538-3508
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 01055166A
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License Number State | IN
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