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General NPI Number Information
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NPI Number | 1740360619
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Entity Type | Individual
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Provider Name | JOHN RICHARD LAKE MD
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Gender | Male
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 10/26/2012
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Provider Practice Location Address
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Address Line | UNIVERSITY OF MINNESOTA PHYSICIANS 516 DELAWARE STREET SE, CLINIC 2A
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City | MINNEAPOLIS
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State | MN
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Zip | 55454-1478
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Country | US
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Telephone | 612-626-6100
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Fax |
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Provider Business Mailing Address
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Address Line | UNIVERSITY OF MINNESOTA PHYSICIANS 420 DELAWARE ST SE, MMC 36
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City | MINNEAPOLIS
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State | MN
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Zip | 55455
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Country | US
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Telephone | 612-626-6100
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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 | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 40739
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License Number State | MN
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