Provider Demographics
NPI:1407944051
Name:LAU, STACY MIYAMOTO (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:MIYAMOTO
Last Name:LAU
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 1:95-1011 HOLOLANI ST
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-4960
Mailing Address - Country:US
Mailing Address - Phone:808-626-8426
Mailing Address - Fax:
Practice Address - Street 1:599 FARRINGTON HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2001
Practice Address - Country:US
Practice Address - Phone:808-674-2930
Practice Address - Fax:808-674-2950
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH00965Medicare UPIN
HI51812Medicare ID - Type Unspecified