Provider Demographics
NPI:1114029485
Name:LU, RONG-BAO (MD)
Entity Type:Individual
Prefix:DR
First Name:RONG-BAO
Middle Name:
Last Name:LU
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 1:185 CANAL ST STE 301
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4537
Mailing Address - Country:US
Mailing Address - Phone:212-966-2178
Mailing Address - Fax:212-925-7696
Practice Address - Street 1:185 CANAL ST # 301
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4537
Practice Address - Country:US
Practice Address - Phone:212-966-2178
Practice Address - Fax:212-925-7696
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01818386NYMedicaid
NY01818386NYMedicaid
NYG03787Medicare UPIN