Healthcare Provider Details

I. General information

NPI: 1487810156
Provider Name (Legal Business Name): TIMOTHY LAX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKLINE PL SUITE 623
BROOKLINE MA
02445-7224
US

IV. Provider business mailing address

1 BROOKLINE PL SUITE 623
BROOKLINE MA
02445-7224
US

V. Phone/Fax

Practice location:
  • Phone: 617-278-8100
  • Fax:
Mailing address:
  • Phone: 617-278-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number036120469
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number248449
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number248449
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: