Healthcare Provider Details

I. General information

NPI: 1730526260
Provider Name (Legal Business Name): SAMUEL C. LAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date: 03/31/2014
Reactivation Date: 05/01/2014

III. Provider practice location address

4321 FIR ST
EAST CHICAGO IN
46312-3049
US

IV. Provider business mailing address

4321 FIR ST STE 216
EAST CHICAGO IN
46312-3049
US

V. Phone/Fax

Practice location:
  • Phone: 305-355-8264
  • Fax:
Mailing address:
  • Phone: 219-392-7025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number131707
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number01082675A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: