Provider Demographics
NPI:1912906686
Name:LAKE, NORMA SALENAH (MD)
Entity type:Individual
Prefix:DR
First Name:NORMA
Middle Name:SALENAH
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:11160 SW 88TH STREET
Mailing Address - Street 2:SUITES 104 & 105
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-0949
Mailing Address - Country:US
Mailing Address - Phone:786-263-0911
Mailing Address - Fax:786-263-0761
Practice Address - Street 1:11160 SW 88TH STREET
Practice Address - Street 2:SUITES 104 & 105
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-0949
Practice Address - Country:US
Practice Address - Phone:786-263-0911
Practice Address - Fax:786-263-0761
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35068277207Q00000X
FLME 81467207Q00000X
MI4595588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0637962OtherAETNA
OH578183170-007OtherMMOH
OH080130460OtherRRMC
OH01-03310OtherUHC
OH0151642Medicaid
OH000000141284OtherANTHEM
OHG03292Medicare UPIN
OH0637962OtherAETNA