Provider Demographics
NPI:1114331204
Name:LAM, TIDA (DO)
Entity Type:Individual
Prefix:
First Name:TIDA
Middle Name:
Last Name:LAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:10900 WORLD TRADE BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4202
Mailing Address - Country:US
Mailing Address - Phone:630-740-0574
Mailing Address - Fax:603-228-7307
Practice Address - Street 1:1964 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587
Practice Address - Country:US
Practice Address - Phone:919-554-0177
Practice Address - Fax:919-554-9277
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA271164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine