Healthcare Provider Details

I. General information

NPI: 1306903067
Provider Name (Legal Business Name): JACKSON LAU O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N ROXBURY DR STE 310
BEVERLY HILLS CA
90210-5005
US

IV. Provider business mailing address

435 N ROXBURY DR STE 310
BEVERLY HILLS CA
90210-5005
US

V. Phone/Fax

Practice location:
  • Phone: 310-570-2508
  • Fax:
Mailing address:
  • Phone: 310-570-2508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12975T
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPT 12975
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: