Provider Demographics
NPI:1740712751
Name:LUM, NICOLE MARIE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:205 N BELLE MEAD RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3483
Mailing Address - Country:US
Mailing Address - Phone:631-444-4630
Mailing Address - Fax:631-444-4652
Practice Address - Street 1:205 N BELLE MEAD RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3483
Practice Address - Country:US
Practice Address - Phone:631-444-4630
Practice Address - Fax:631-444-4652
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY305979207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine