Provider Demographics
NPI:1770506537
Name:LAU, DIANA W (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:W
Last Name:LAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 W GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695
Mailing Address - Country:US
Mailing Address - Phone:530-666-1631
Mailing Address - Fax:
Practice Address - Street 1:632 W GIBSON RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-666-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77103207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G771030OtherBLUE SHIELD
CA00G771030Medicaid
CA660002220OtherRR MEDICARE
F82153Medicare UPIN
CA00G771030Medicare ID - Type Unspecified