Provider Demographics
NPI:1750463949
Name:LAM, WILFRED (MD)
Entity Type:Individual
Prefix:
First Name:WILFRED
Middle Name:
Last Name:LAM
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 1:747 N RUTLEDGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6700
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-788-7032
Practice Address - Street 1:747 N RUTLEDGE ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6700
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-788-7032
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-057135174400000X
IL036057135207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057135Medicaid
IL060040344OtherRAILROAD
ILL92319Medicare PIN
ILC44182Medicare UPIN
IL036057135Medicaid