Provider Demographics
NPI:1548503907
Name:LAKE, MICHAEL WOLFGANG (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WOLFGANG
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2500 MARYLAND RD STE 400
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1225
Mailing Address - Country:US
Mailing Address - Phone:215-481-4143
Mailing Address - Fax:215-481-6790
Practice Address - Street 1:1235 OLD YORK RD STE G121
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3800
Practice Address - Country:US
Practice Address - Phone:215-517-1200
Practice Address - Fax:215-517-1219
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.063687207R00000X
PAMD460603207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine