Provider Demographics
NPI:1639147796
Name:LU, OLIVER LEYSON (PT)
Entity Type:Individual
Prefix:MR
First Name:OLIVER
Middle Name:LEYSON
Last Name:LU
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 1:359 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-7436
Mailing Address - Country:US
Mailing Address - Phone:212-529-2184
Mailing Address - Fax:212-529-2186
Practice Address - Street 1:359 2ND AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7436
Practice Address - Country:US
Practice Address - Phone:212-777-8490
Practice Address - Fax:212-777-8496
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02203134Medicaid
NY02203134Medicaid