Provider Demographics
NPI:1487810156
Name:LAX, TIMOTHY (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:LAX
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 1:1 BROOKLINE PL
Mailing Address - Street 2:SUITE 623
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7224
Mailing Address - Country:US
Mailing Address - Phone:617-278-8100
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKLINE PL
Practice Address - Street 2:SUITE 623
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7224
Practice Address - Country:US
Practice Address - Phone:617-278-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361204692080P0207X
MA248449207K00000X, 207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120469OtherMEDICAL LICENSE NUMBER
MA248449OtherMEDICAL LICENSE