Basic Information
| Provider Information | |||||||||
| NPI: | 1730526260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAU | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4321 FIR ST STE 216 | ||||||||
| Address2: | |||||||||
| City: | EAST CHICAGO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463123049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927025 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4321 FIR ST | ||||||||
| Address2: | |||||||||
| City: | EAST CHICAGO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463123049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053558264 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2013 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/31/2014 | ||||||||
| NPIReactivationDate: | 05/01/2014 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 131707 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | 01082675A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
No ID Information.