Provider Demographics
NPI:1457056442
Name:LAU, ETHAN WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:WESLEY
Last Name:LAU
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 1:1501 RED RIVER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1845
Mailing Address - Country:US
Mailing Address - Phone:512-495-5555
Mailing Address - Fax:
Practice Address - Street 1:1501 RED RIVER ST FL 2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1845
Practice Address - Country:US
Practice Address - Phone:512-495-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7648672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry