Basic Information
| Provider Information | |||||||||
| NPI: | 1992736888 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | D.Y. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 STATE ROUTE 59 | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442404112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306773632 | ||||||||
| FaxNumber: | 3305723836 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 STATE ROUTE 59 | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442404112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306773632 | ||||||||
| FaxNumber: | 3305723836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35.041595 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0016482521 | 01 | PA | HIGHMARK | OTHER | 101167147 | 05 | PA | MEDICAID | 0448706 | 05 | OH | MEDICAID |