Healthcare Provider Details

I. General information

NPI: 1114331204
Provider Name (Legal Business Name): TIDA LAM D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1964 S MAIN ST
WAKE FOREST NC
27587
US

IV. Provider business mailing address

10900 WORLD TRADE BLVD
RALEIGH NC
27617-4202
US

V. Phone/Fax

Practice location:
  • Phone: 919-554-0177
  • Fax: 919-554-9277
Mailing address:
  • Phone: 630-740-0574
  • Fax: 603-228-7307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number271164
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: