Provider Demographics
NPI:1902884695
Name:LAKE, GARY J (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:LAKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:200 MIDWAY PARK DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2642
Mailing Address - Country:US
Mailing Address - Phone:845-343-6919
Mailing Address - Fax:845-343-4545
Practice Address - Street 1:200 MIDWAY PARK DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2642
Practice Address - Country:US
Practice Address - Phone:845-343-6919
Practice Address - Fax:845-343-4545
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYT5072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC40861Medicare PIN
NYC40861Medicare UPIN