Provider Demographics
NPI:1023076874
Name:LAKE, LADD DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:LADD
Middle Name:DANIEL
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 362
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69103-0362
Mailing Address - Country:US
Mailing Address - Phone:866-477-7013
Mailing Address - Fax:866-902-2445
Practice Address - Street 1:601 W LEOTA ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6525
Practice Address - Country:US
Practice Address - Phone:308-696-7491
Practice Address - Fax:308-696-7432
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE221472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE243897OtherMIDLANDS CHOICE
IA0585794Medicaid
NE1603089OtherSHARE ADVANTAGE
NE605082700OtherUS DEPARTMENT OF LABOR
NE04192OtherBC/BS OF NEBRASKA
NE10025186700Medicaid
IA20050OtherWELLMARK BC/BS
NE04192OtherBC/BS OF NEBRASKA
IA0585794Medicaid
NE10025186700Medicaid
IAI17607Medicare PIN
NE605082700OtherUS DEPARTMENT OF LABOR