Provider Demographics
NPI:1760857148
Name:ADVANCED MEDICAL LASER OPTIONS LLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL LASER OPTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-361-4961
Mailing Address - Street 1:97 CEDAR VILLAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-8716
Mailing Address - Country:US
Mailing Address - Phone:732-361-4961
Mailing Address - Fax:
Practice Address - Street 1:1398 HWY 35
Practice Address - Street 2:SUITE 6
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-3543
Practice Address - Country:US
Practice Address - Phone:732-361-4961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA045101002086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty