Provider Demographics
NPI:1750383808
Name:LAI, JENGYU (DPM)
Entity type:Individual
Prefix:DR
First Name:JENGYU
Middle Name:
Last Name:LAI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 WELLNER DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-8427
Mailing Address - Country:US
Mailing Address - Phone:507-218-3095
Mailing Address - Fax:507-218-3097
Practice Address - Street 1:3070 WELLNER DR NE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-8427
Practice Address - Country:US
Practice Address - Phone:507-218-3095
Practice Address - Fax:507-218-3097
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN635213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN819693100Medicaid
MN480000723Medicare UPIN
MN819693100Medicaid
MN4555680001Medicare NSC