Provider Demographics
NPI:1144367111
Name:LAU, JONATHAN B (DO)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:LAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5486
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5486
Mailing Address - Country:US
Mailing Address - Phone:818-550-0900
Mailing Address - Fax:505-293-1524
Practice Address - Street 1:716 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1010
Practice Address - Country:US
Practice Address - Phone:818-550-0900
Practice Address - Fax:505-293-1524
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7545207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX75450Medicaid
CAH38575Medicare UPIN
CA00AX75450Medicaid
CA20A7545CMedicare ID - Type Unspecified