Provider Demographics
NPI:1073653150
Name:LAU, GLEN K (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:K
Last Name:LAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 GRAND AVE
Mailing Address - Street 2:STE. 810
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3725
Mailing Address - Country:US
Mailing Address - Phone:510-451-6950
Mailing Address - Fax:510-451-0785
Practice Address - Street 1:80 GRAND AVE
Practice Address - Street 2:STE. 810
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3725
Practice Address - Country:US
Practice Address - Phone:510-451-6950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28241208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery