Basic Information
| Provider Information | |||||||||
| NPI: | 1720085244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAU | ||||||||
| FirstName: | DIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 S 19TH ST | ||||||||
| Address2: | STE 1B | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191461449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155454173 | ||||||||
| FaxNumber: | 2155451543 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 S 19TH ST | ||||||||
| Address2: | STE 1B | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191461449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155454173 | ||||||||
| FaxNumber: | 2155451543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD052887L | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | LA780285 | 01 | PA | PA BLUE SHIELD | OTHER | 0015297620002 | 05 | PA | MEDICAID | 6568203 | 05 | NJ | MEDICAID |