Basic Information
| Provider Information | |||||||||
| NPI: | 1619979564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035702006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522040 | ||||||||
| FaxNumber: | 6037521709 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035702006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522040 | ||||||||
| FaxNumber: | 6037527797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 06/30/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9702 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BL5047039 | 01 | FEDERAL DEA# | OTHER | 5830418 | 01 | AETNA GROUP | OTHER | 0103651YPNH01 | 01 | NH | ANTHEM BC/BS | OTHER | 9702 | 01 | NH | STATE LICENSE # | OTHER | 080183074 | 01 | RAILROAD MEDICARE | OTHER | 30009864 | 05 | NH | MEDICAID | 6861833 | 01 | NH | CIGNA HEALTHCARE | OTHER |