Provider Demographics
NPI:1275575722
Name:LAU, STELLA KIM (OD)
Entity Type:Individual
Prefix:DR
First Name:STELLA
Middle Name:KIM
Last Name:LAU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8282 BEAVERBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-0837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4116 W CRAIG RD STE 104
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-2733
Practice Address - Country:US
Practice Address - Phone:702-631-2015
Practice Address - Fax:702-631-2511
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12895152W00000X
HI634152W00000X
UT5949006-9934152W00000X
NV589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM48830739Medicaid
NV1275575722Medicaid
AZ950685Medicaid
CO75507242Medicaid
8HF656Medicare PIN
NV1275575722Medicaid
NMV05904Medicare UPIN
320059Medicare Oscar/Certification