Basic Information
| Provider Information | |||||||||
| NPI: | 1194808394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3014 | ||||||||
| Address2: | 1215 DUFF AVENUE | ||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500103014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152394456 | ||||||||
| FaxNumber: | 5152394761 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 DUFF AVENUE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500103014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152394456 | ||||||||
| FaxNumber: | 5152394761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 37861 | IA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 23902 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 24188 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | A99351 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01626 | 01 | BC/BS NE | OTHER | 10025186700 | 05 | NE | MEDICAID | 10025173600 | 05 | NE | MEDICAID | 69958751 | 05 | CO | MEDICAID | 1194808394 | 05 | IA | MEDICAID | 200145166 | 01 | IA | WELLMARK SELECT FIRST | OTHER | 201477608 | 01 | IA | WELLMARK SELECT FIRST | OTHER | P00619095 | 01 | IA | RR MEDICARE | OTHER | P00619099 | 01 | NE | RR MEDICARE | OTHER | 7729430 | 05 | SD | MEDICAID | 10025248800 | 05 | NE | MEDICAID | 34783 | 01 | BC/BS NE | OTHER |