Provider Demographics
NPI:1275776528
Name:LU, JOHNNY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
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 1:299 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3026
Mailing Address - Country:US
Mailing Address - Phone:203-288-4288
Mailing Address - Fax:203-288-1566
Practice Address - Street 1:299 WASHINGTON AVE STE LL
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3039
Practice Address - Country:US
Practice Address - Phone:203-288-4288
Practice Address - Fax:855-414-4010
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN116257874208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT8059293Medicaid