Provider Demographics
NPI:1407198724
Name:LAM, IDA MAN SHAN (RD)
Entity Type:Individual
Prefix:MS
First Name:IDA
Middle Name:MAN SHAN
Last Name:LAM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 BOWNE ST
Mailing Address - Street 2:STE L3
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5606
Mailing Address - Country:US
Mailing Address - Phone:718-961-1496
Mailing Address - Fax:718-961-1494
Practice Address - Street 1:4110 BOWNE ST
Practice Address - Street 2:STE L3
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5606
Practice Address - Country:US
Practice Address - Phone:718-961-1496
Practice Address - Fax:718-961-1494
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1020937133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered