Provider Demographics
NPI:1376893974
Name:LAI, KENNETH ETHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ETHAN
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 1:6968 PHILLIPS RESERVE CT FL 7208W
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7809
Mailing Address - Country:US
Mailing Address - Phone:407-558-0188
Mailing Address - Fax:407-440-4307
Practice Address - Street 1:7208 W SAND LAKE RD STE 305
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5279
Practice Address - Country:US
Practice Address - Phone:407-799-8808
Practice Address - Fax:407-440-4307
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1148912084P0800X
CT0539412084P0800X
WAMD603530182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1184190753OtherMEDICARE PART B
FL1184190753OtherMEDICARE