Provider Demographics
NPI:1861837338
Name:LAM, JASON KHOA (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:KHOA
Last Name:LAM
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 1:1402 S GRAND BLVD RM 157
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1004
Mailing Address - Country:US
Mailing Address - Phone:314-977-8887
Mailing Address - Fax:
Practice Address - Street 1:1402 S GRAND BLVD RM 157
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1004
Practice Address - Country:US
Practice Address - Phone:314-977-8887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020471207R00000X, 208000000X, 390200000X
MO2017011857390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics