Provider Demographics
NPI:1043835069
Name:LAM, JESSE AUSTIN (OD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:AUSTIN
Last Name:LAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7234 W KIMBERLY WAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5857
Mailing Address - Country:US
Mailing Address - Phone:623-628-6841
Mailing Address - Fax:
Practice Address - Street 1:13371 W GRAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7063
Practice Address - Country:US
Practice Address - Phone:623-556-8083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ002430152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist