Provider Demographics
NPI:1760568943
Name:LAO, JUANITA ONG (MD)
Entity Type:Individual
Prefix:DR
First Name:JUANITA
Middle Name:ONG
Last Name:LAO
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 1:121 DE KALB AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201
Mailing Address - Country:US
Mailing Address - Phone:718-789-1116
Mailing Address - Fax:
Practice Address - Street 1:333 LAFAYETTE AVE
Practice Address - Street 2:#PB
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238
Practice Address - Country:US
Practice Address - Phone:718-789-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2010-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115220208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00211918Medicaid
NY00211918Medicaid
NY284381Medicare ID - Type Unspecified