Provider Demographics
NPI:1063698330
Name:LAKE, CLIFTON RUDOLPH (MD)
Entity type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:RUDOLPH
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-2416
Mailing Address - Country:US
Mailing Address - Phone:516-508-0128
Mailing Address - Fax:
Practice Address - Street 1:46 BROOK RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-2416
Practice Address - Country:US
Practice Address - Phone:516-508-0128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN11192084P0800X
NYP60621283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry