Individual
DR. RUSSELL WILLIAM LAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
10055 FORD AVENUE, SUITE 3A, RICHMOND HILL, GA 31324
(912) 819-9601
(912) 819-9605
Mailing address
836 E. 65TH STREET, SUITE 22, SAVANNAH, GA 31405
(912) 819-7878
(912) 819-3320
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
31545
SC
207Q00000X
Family Medicine Physician
Primary
75198
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003213522B
—
GA
05
—
200480198D
—
GA
Enumeration date
07/21/2008
Last updated
10/19/2021
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