Physician Compare National (NPI:1104848423)

HEALTHCARE PROVIDER: MARK ADRIAN LAKE M.D.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1104848423
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	2365425857
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20040607001474
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	LAKE
	Individual professional last name
Provider First Name	MARK
	Individual professional first name
Provider Middle Name	A
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.
Provider Credential Text	MD
	The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.

Medical School Information
Medical School Name	WRIGHT STATE UNIVERSITY BOONSHOFT SCHOOL OF MEDICINE
	Individual professional's medical school
Graduation Year	1996
	Individual professional's medical school graduation year
Primary Specialty	DERMATOLOGY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	15 EXECUTIVE DR
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 4
	Group Practice or individual's line 2 address
City	LAFAYETTE
	Group Practice or individual's city
State	IN
	Group Practice or individual's state
Zip Code	479054868
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	150173
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	INDIANA UNIVERSITY HEALTH ARNETT HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Professional Accepts Medicare Assignment	Y