Provider Demographics
NPI:1124184304
Name:LAM, MIMI (MD)
Entity Type:Individual
Prefix:DR
First Name:MIMI
Middle Name:
Last Name:LAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 LOFTUS LN
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2717
Mailing Address - Country:US
Mailing Address - Phone:612-767-6000
Mailing Address - Fax:612-767-6600
Practice Address - Street 1:5725 LOFTUS LN
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2717
Practice Address - Country:US
Practice Address - Phone:612-767-6000
Practice Address - Fax:612-767-6600
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39369207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG44546Medicare UPIN
MN70000499Medicare ID - Type Unspecified