Provider Demographics
NPI:1720306632
Name:LAKE, TAMAR (MD)
Entity type:Individual
Prefix:
First Name:TAMAR
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E MEDICAL CENTER DR
Mailing Address - Street 2:1H247
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-5000
Mailing Address - Country:US
Mailing Address - Phone:734-936-4280
Mailing Address - Fax:734-936-9091
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2303
Practice Address - Country:US
Practice Address - Phone:734-769-7100
Practice Address - Fax:734-936-9091
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-17
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
MI4301096607207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program