Provider Demographics
NPI:1407303647
Name:LUTY, ELLIOTT (DPT)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:LUTY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 UTOPIA PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-4142
Mailing Address - Country:US
Mailing Address - Phone:718-819-6805
Mailing Address - Fax:347-841-9109
Practice Address - Street 1:530 KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2140
Practice Address - Country:US
Practice Address - Phone:201-523-9207
Practice Address - Fax:201-523-9208
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01683800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY255015Medicare PIN