Healthcare Provider Details

I. General information

NPI: 1790941367
Provider Name (Legal Business Name): KELVIN CHEUKHANG LAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 06/13/2021
Certification Date: 06/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 W MLK JR. BLVD 3RD FLOOR
TAMPA FL
33607-6307
US

IV. Provider business mailing address

625 6TH AVE S STE 120
ST PETERSBURG FL
33701-4654
US

V. Phone/Fax

Practice location:
  • Phone: 813-554-8701
  • Fax:
Mailing address:
  • Phone: 727-322-4830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number48279
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT192388
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number48279
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: