Provider Demographics
NPI:1790784692
Name:LAM, MAN TAI (MD)
Entity Type:Individual
Prefix:
First Name:MAN
Middle Name:TAI
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:PO BOX 371581
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79937-1581
Mailing Address - Country:US
Mailing Address - Phone:915-598-1600
Mailing Address - Fax:915-351-6040
Practice Address - Street 1:1221 N COTTON ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3015
Practice Address - Country:US
Practice Address - Phone:915-598-1600
Practice Address - Fax:915-351-6040
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4916207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130349701Medicaid
TX130349701Medicaid
C18102Medicare UPIN