Provider Demographics
NPI:1558563205
Name:LAKS, SHACHAR (MD)
Entity Type:Individual
Prefix:
First Name:SHACHAR
Middle Name:
Last Name:LAKS
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:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MOYE BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4300
Practice Address - Country:US
Practice Address - Phone:252-744-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116803208600000X
MO2009019133208600000X
NC2016-001932086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1558563205Medicaid
NCNCY4050322OtherMEDICARE
NC1558563205Medicaid
NC19QDCOtherBCBS OF NC
MO3032600OtherUNITED HEALTHCARE
MO96626OtherHEALTHCARE USA
MO013370003Medicare PIN
MOMA3716005Medicare PIN
MO3032600OtherUNITED HEALTHCARE