Individual
SCOTT LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
5707 W NORTHERN AVE STE 106, GLENDALE, AZ 85301-1355
(602) 512-3299
Mailing address
220 N MCKEMY AVE, CHANDLER, AZ 85226-2651
(480) 961-1865
(480) 961-0794
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
002756
CT
152W00000X
Optometrist
Primary
2519
AZ
Other
Enumeration date
08/01/2008
Last updated
09/21/2021
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