=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881715704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER THEINWIN LAM M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 11/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36065 SANTA FE AVE.
-----------------------------------------------------
City | FT. HOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-553-1256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36065 SANTA FE AVE.
-----------------------------------------------------
City | FT. HOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-553-1256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171000000X
-----------------------------------------------------
Taxonomy Name | Military Health Care Provider
-----------------------------------------------------
License Number | 03-404949
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207U00000X
-----------------------------------------------------
Taxonomy Name | Nuclear Medicine Physician
-----------------------------------------------------
License Number | 038898
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------