Individual
JACK RUSSELLE LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
2624 DAWSON RD, ALBANY, GA 31707-1609
(229) 888-1624
Mailing address
700 E MOREHEAD ST STE 300, CHARLOTTE, NC 28202-2742
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
101304
GA
2085R0202X
Diagnostic Radiology Physician
Primary
4205
OK
Other
Enumeration date
02/05/2007
Last updated
10/30/2024
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