Basic Information
| Provider Information | |||||||||
| NPI: | 1205986312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAU | ||||||||
| FirstName: | THEODORE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 YAKIMA AVE STE 307 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2536273520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE STE 307 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2536273520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00041200 | WA | N | Other Service Providers | Specialist | 207RI0011X | MD00041200 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | MD00041200 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | MD00041200 | WA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 0168601 | 01 | WA | DEPARTMENT OF L&I | OTHER | P00008350 | 01 | WA | RAILROAD MEDICARE | OTHER | 1300LA | 01 | WA | REGENCE | OTHER | 4751LA | 01 | WA | REGENCE | OTHER | 1708LA | 01 | WA | REGENCE | OTHER | 1004592 | 05 | WA | MEDICAID | 1802LA | 01 | WA | REGENCE | OTHER |