Provider Demographics
NPI:1821077975
Name:LUM, DIANE LAU (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LAU
Last Name:LUM
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 1:228 W TYLER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4223
Mailing Address - Country:US
Mailing Address - Phone:870-735-1973
Mailing Address - Fax:870-735-5433
Practice Address - Street 1:6005 PARK AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5212
Practice Address - Country:US
Practice Address - Phone:901-761-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29884207R00000X
ARE1289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131640001Medicaid
AR131640001Medicaid
5K463Medicare ID - Type Unspecified