Provider Demographics
NPI:1366485757
Name:LAI, JIM (MD)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:
Last Name:LAI
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:PO BOX 1972
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91507-1972
Mailing Address - Country:US
Mailing Address - Phone:818-988-3123
Mailing Address - Fax:
Practice Address - Street 1:4929 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1702
Practice Address - Country:US
Practice Address - Phone:818-907-4570
Practice Address - Fax:818-907-2814
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89768207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A897680Medicaid
CAH78335Medicare UPIN
CAWA89768BMedicare PIN
CAWA89768EMedicare PIN
CA00A897680Medicaid