Provider Demographics
NPI:1063237360
Name:ANGEL LAKE, MD
Entity type:Organization
Organization Name:ANGEL LAKE, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:340-332-3665
Mailing Address - Street 1:PO BOX 1051
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00821-1051
Mailing Address - Country:US
Mailing Address - Phone:340-332-3665
Mailing Address - Fax:210-682-9509
Practice Address - Street 1:4007 ESTATE DIAMOND RUBY
Practice Address - Street 2:
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820-4435
Practice Address - Country:US
Practice Address - Phone:340-332-3665
Practice Address - Fax:210-682-9509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-20
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty