Provider Demographics
NPI:1063591667
Name:GARY T. LAI, M.D.
Entity type:Organization
Organization Name:GARY T. LAI, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-548-3888
Mailing Address - Street 1:PO BOX 2703
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91708-2703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14335 PIPELINE AVE
Practice Address - Street 2:A-1
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5642
Practice Address - Country:US
Practice Address - Phone:909-548-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A650300Medicaid
CA00A650300Medicaid
H06902Medicare UPIN