Provider Demographics
NPI:1790479996
Name:JIANG, LAI (OD)
Entity Type:Individual
Prefix:
First Name:LAI
Middle Name:
Last Name:JIANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4847 E ROUTE 36
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-9736
Mailing Address - Country:US
Mailing Address - Phone:217-425-3219
Mailing Address - Fax:217-425-3220
Practice Address - Street 1:1721 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-3161
Practice Address - Country:US
Practice Address - Phone:608-837-7325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3913-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist