Healthcare Provider Details

I. General information

NPI: 1962498956
Provider Name (Legal Business Name): PHILIP ALLAN LA KIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LUKE AVE RM 405
BOLLING AFB DC
20032-6400
US

IV. Provider business mailing address

110 LUKE AVE RM 405
BOLLING AFB DC
20032-6400
US

V. Phone/Fax

Practice location:
  • Phone: 202-767-4200
  • Fax:
Mailing address:
  • Phone: 202-767-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number54443
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: