Provider Demographics
NPI:1992736888
Name:LAN, DAVID DY (M D)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DY
Last Name:LAN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 STATE ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-4112
Mailing Address - Country:US
Mailing Address - Phone:330-677-3632
Mailing Address - Fax:330-572-3836
Practice Address - Street 1:1930 STATE ROUTE 59
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4112
Practice Address - Country:US
Practice Address - Phone:330-677-3632
Practice Address - Fax:330-572-3836
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0415952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016482521OtherHIGHMARK
PA101167147Medicaid
OH0448706Medicaid
PA101167147Medicaid
OH0462694Medicare PIN
OH0462693Medicare PIN
OH0462693Medicare PIN
OH0462694Medicare PIN