Provider Demographics
NPI:1144511908
Name:JUANITA O LAO MD PC
Entity type:Organization
Organization Name:JUANITA O LAO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:ONG
Authorized Official - Last Name:LAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-789-1116
Mailing Address - Street 1:121 DE KALB AVE.
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5425
Mailing Address - Country:US
Mailing Address - Phone:718-789-1116
Mailing Address - Fax:
Practice Address - Street 1:333 LAFAYETTE AVE
Practice Address - Street 2:SUITE PB
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-1350
Practice Address - Country:US
Practice Address - Phone:718-789-1116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUANITA O LAO MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115220261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00211918Medicaid
NYB12211Medicare UPIN