Provider Demographics
NPI:1326140328
Name:LACKOWITZ, JEFFREY (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:LACKOWITZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 WAVERLY AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1597
Mailing Address - Country:US
Mailing Address - Phone:631-758-5700
Mailing Address - Fax:631-758-7005
Practice Address - Street 1:440 WAVERLY AVE STE 5
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1597
Practice Address - Country:US
Practice Address - Phone:631-758-5700
Practice Address - Fax:631-758-7005
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014079-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5442410OtherAETNA
NY102491OtherVYTRA
NY2284678OtherAETNA
NY940212OtherHERITAGE
NYAZ00653OtherMDNY
NY1437802OtherFIRST HEALTH
NYQ49881OtherEMPIRE BLUE CROSS
NYP1948798OtherOXFORD
NM1380287OtherUNITED HEALTH CARE
NY20593POtherHIP
NYSF0003106OtherSELECT PRO
NYQ49881OtherEMPIRE BLUE CROSS