Provider Demographics
NPI:1679554505
Name:FONACIER, LUZ S (MD)
Entity Type:Individual
Prefix:DR
First Name:LUZ
Middle Name:S
Last Name:FONACIER
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 1:120 MINEOLA BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4073
Mailing Address - Country:US
Mailing Address - Phone:516-663-4751
Mailing Address - Fax:516-663-2946
Practice Address - Street 1:120 MINEOLA BLVD
Practice Address - Street 2:SUITE 410
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4073
Practice Address - Country:US
Practice Address - Phone:516-663-4751
Practice Address - Fax:516-663-2946
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYS164053207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01207652Medicaid
NY64F212Medicare ID - Type Unspecified
NY01207652Medicaid