Provider Demographics
NPI:1407816705
Name:PAK, LUCILLE L (MD)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:L
Last Name:PAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MOTT STREET #203
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013
Mailing Address - Country:US
Mailing Address - Phone:212-227-4505
Mailing Address - Fax:212-227-4579
Practice Address - Street 1:2 MOTT STREET #203
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013
Practice Address - Country:US
Practice Address - Phone:212-227-4505
Practice Address - Fax:212-227-4579
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174841207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01105751Medicaid
E44707Medicare UPIN
NY35F971Medicare ID - Type Unspecified