Healthcare Provider Details

I. General information

NPI: 1669768511
Provider Name (Legal Business Name): JONATHAN TONY LAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

PIMC - PNC PO BOX 31001-0698
PASADENA CA
91110-0698
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1200
  • Fax:
Mailing address:
  • Phone: 602-263-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA122262
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: