Basic Information
| Provider Information | |||||||||
| NPI: | 1003952375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | DIANAH | ||||||||
| MiddleName: | THELMA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANSON | ||||||||
| OtherFirstName: | DIANAH | ||||||||
| OtherMiddleName: | THELMA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8 LEO TER | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070034414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9173342381 | ||||||||
| FaxNumber: | 9733381041 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 PELHAM PKWY S | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104611138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189185820 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MA08177800 | NJ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD21481 | ME | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.