Provider Demographics
NPI:1194808394
Name:LAKE, DOUGLAS R (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
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:PO BOX 3014
Mailing Address - Street 2:1215 DUFF AVENUE
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-3014
Mailing Address - Country:US
Mailing Address - Phone:515-239-4456
Mailing Address - Fax:515-239-4761
Practice Address - Street 1:1215 DUFF AVENUE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-3014
Practice Address - Country:US
Practice Address - Phone:515-239-4456
Practice Address - Fax:515-239-4761
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA378612085R0202X
SC239022085R0202X
NE241882085R0202X
CAA993512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
01626OtherBC/BS NE
NE10025186700Medicaid
NE10025173600Medicaid
CO69958751Medicaid
IA1194808394Medicaid
IA200145166OtherWELLMARK SELECT FIRST
IA201477608OtherWELLMARK SELECT FIRST
IAP00619095OtherRR MEDICARE
NEP00619099OtherRR MEDICARE
SD7729430Medicaid
NE10025248800Medicaid
34783OtherBC/BS NE
CO69958751Medicaid
IAI14677001Medicare PIN