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NPI Code Detail

MEDICARE: DR. ERIC J LAKE DO

MEDICARE: DR. ERIC J LAKE DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207QS0010XSports Medicine (Family Medicine) PhysicianOS012275PA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1710919139
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ERIC J LAKE DO
Provider Business Mailing Address
First Line : 525 W CHESTER PIKE
Second Line : SUITE 203
City : HAVERTOWN
State : PA
Zip : 19083-4500
Country : US
Telephone Number : 610-789-7767
Fax Number : 610-789-7768
Provider Business Practice Location Address
First Line : 525 W CHESTER PIKE
Second Line : SUITE 203
City : HAVERTOWN
State : PA
Zip : 19083-4500
Country : US
Telephone Number : 610-789-7767
Fax Number : 610-789-7768
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/07/2006
Last Update Date : 07/18/2012

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