Individual
DR. JOHN RUSSELL LAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
5565 GROSSMONT CENTER DR, BLDG 3 SUITE 256, LA MESA, CA 91942-3020
(619) 462-3131
(619) 462-1731
Mailing address
5565 GROSSMONT CENTER DR, BLDG 3 SUITE 256, LA MESA, CA 91942-3020
(619) 462-3131
(619) 462-1731
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
G14553
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
ZZZ72232Z
—
AR
Enumeration date
07/11/2006
Last updated
07/09/2007
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