Provider Demographics
NPI:1164576385
Name:LUZATO MEDICAL GROUP P.C.
Entity Type:Organization
Organization Name:LUZATO MEDICAL GROUP P.C.
Other - Org Name:COLLEGE POINT MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-461-9105
Mailing Address - Street 1:1812 COLLEGE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-2221
Mailing Address - Country:US
Mailing Address - Phone:718-461-9105
Mailing Address - Fax:716-461-3392
Practice Address - Street 1:1812 COLLEGE POINT BLVD
Practice Address - Street 2:
Practice Address - City:COLLEGE POINT
Practice Address - State:NY
Practice Address - Zip Code:11356-2221
Practice Address - Country:US
Practice Address - Phone:718-461-9105
Practice Address - Fax:716-461-3392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Not Answered208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5501024OtherGHI
NY01156Medicare ID - Type UnspecifiedGHI MEDICARE