Provider Demographics
NPI:1235113457
Name:LAO, IRENE O (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:O
Last Name:LAO
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 1:931 BUENA VISTA ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-1712
Mailing Address - Country:US
Mailing Address - Phone:626-303-4626
Mailing Address - Fax:
Practice Address - Street 1:931 BUENA VISTA ST
Practice Address - Street 2:SUITE 201
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-1712
Practice Address - Country:US
Practice Address - Phone:626-303-4626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41174207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A411740Medicaid
CAA29320Medicare UPIN