Provider Demographics
NPI:1003048448
Name:LAO, WILBERT
Entity Type:Individual
Prefix:
First Name:WILBERT
Middle Name:
Last Name:LAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 SUMMERFIELD ST
Mailing Address - Street 2:APT A1
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5839
Mailing Address - Country:US
Mailing Address - Phone:646-239-2756
Mailing Address - Fax:
Practice Address - Street 1:37 W 26TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1006
Practice Address - Country:US
Practice Address - Phone:718-285-0588
Practice Address - Fax:718-285-9323
Is Sole Proprietor?:No
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016725225100000X
NY030205-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist