Provider Demographics
NPI:1477791143
Name:LAHAM, AILEE MARK (MD)
Entity Type:Individual
Prefix:
First Name:AILEE
Middle Name:MARK
Last Name:LAHAM
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 1:320 PROSPERITY DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4709
Mailing Address - Country:US
Mailing Address - Phone:423-756-1512
Mailing Address - Fax:
Practice Address - Street 1:1124 E WEISGARBER RD STE 207
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2686
Practice Address - Country:US
Practice Address - Phone:865-588-0811
Practice Address - Fax:865-584-2153
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD17029207W00000X
TN55708207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3850174Medicaid
HIHM173ZMedicare PIN