Provider Demographics
NPI:1881671048
Name:LAU, FRED G (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:G
Last Name:LAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3350 E BIRCH ST
Mailing Address - Street 2:SUITE #105
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6264
Mailing Address - Country:US
Mailing Address - Phone:714-646-8649
Mailing Address - Fax:714-646-8650
Practice Address - Street 1:13100 STUDEBAKER RD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2531
Practice Address - Country:US
Practice Address - Phone:562-868-3751
Practice Address - Fax:562-868-9742
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4121174400000X
CAG717472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105245802Medicaid
TX105245802Medicaid
TX86R459Medicare ID - Type Unspecified