Provider Demographics
NPI:1497958862
Name:LAM SIU, VICENTE (MD)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:
Last Name:LAM SIU
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 1:120 E BEAUREGARD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-5919
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:
Practice Address - Street 1:120 E BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5919
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR9092207R00000X
PR17937207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8KD537OtherBCBS
TX391439201Medicaid