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General NPI Number Information
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NPI Number | 1730179045
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Entity Type | Individual
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Provider Name | MICHAEL THOMAS LAKE M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/27/2005
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Last Update Date | 04/05/2014
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Provider Practice Location Address
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Address Line | 5950 SW 81ST ST
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City | MIAMI
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State | FL
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Zip | 33143-8120
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Country | US
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Telephone | 910-257-4406
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Fax |
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Provider Business Mailing Address
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Address Line | 5950 SW 81ST ST
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City | MIAMI
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State | FL
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Zip | 33143-8120
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Country | US
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Telephone | 910-257-4406
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | K8647
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 2006-00950
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License Number State | NC
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