Provider Demographics
NPI:1780036855
Name:LAU, JEFFREY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:LAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18357 W 13 MILE RD
Mailing Address - Street 2:APT 32
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-8009
Mailing Address - Country:US
Mailing Address - Phone:517-862-1729
Mailing Address - Fax:
Practice Address - Street 1:210 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-2048
Practice Address - Country:US
Practice Address - Phone:248-437-1744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022732390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program