Provider Demographics
NPI:1578503249
Name:LAI, WALLACE I I (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:I
Last Name:LAI
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2480 LIBERTY ST NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8380
Mailing Address - Country:US
Mailing Address - Phone:503-371-1756
Mailing Address - Fax:503-584-7971
Practice Address - Street 1:2480 LIBERTY ST NE
Practice Address - Street 2:SUITE 110
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-8380
Practice Address - Country:US
Practice Address - Phone:503-371-1756
Practice Address - Fax:503-584-7971
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17813207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR060060218OtherRAILROAD MEDICARE
OR100009591Medicaid
OR288256Medicaid
ORR152478Medicare PIN
OR060060218OtherRAILROAD MEDICARE
OR288256Medicaid
ORR134732Medicare PIN