Provider Demographics
NPI:1285769182
Name:LAU, JACOB E (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:E
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 1:2811 N VENTURA RD
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-2213
Mailing Address - Country:US
Mailing Address - Phone:805-983-0343
Mailing Address - Fax:805-983-3285
Practice Address - Street 1:2811 N VENTURA RD
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2213
Practice Address - Country:US
Practice Address - Phone:805-983-0343
Practice Address - Fax:805-983-3285
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75621207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A756210OtherMEDI-CAL
00A756210OtherMEDI-CAL
WA75621BMedicare PIN