Healthcare Provider Details

I. General information

NPI: 1023087673
Provider Name (Legal Business Name): KHOA D LAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 UNITY PL SUITE 210
LAFAYETTE IN
47905-5762
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-5432
  • Fax: 765-446-5431
Mailing address:
  • Phone: 765-449-2732
  • Fax: 765-449-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01044085A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: