Provider Demographics
NPI:1962433235
Name:LAU, MARK M (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
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 1:2826 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-4809
Mailing Address - Country:US
Mailing Address - Phone:707-443-8066
Mailing Address - Fax:707-268-3250
Practice Address - Street 1:2826 HARRIS ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4809
Practice Address - Country:US
Practice Address - Phone:707-443-8066
Practice Address - Fax:707-268-3250
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31865207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G318650Medicaid
00G318651Medicare PIN
CA00G318650Medicaid