Provider Demographics
NPI:1679565501
Name:LAI, AMY (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10021 DUPONT CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1604
Mailing Address - Country:US
Mailing Address - Phone:260-426-8117
Mailing Address - Fax:260-420-0817
Practice Address - Street 1:1169 N MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-1360
Practice Address - Country:US
Practice Address - Phone:260-827-4368
Practice Address - Fax:260-827-4370
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055046A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200376870Medicaid
OH2407809Medicaid
ININ1333040Medicare PIN
ING92909Medicare UPIN
IN200376870Medicaid
OH2407809Medicaid