Provider Demographics
NPI:1801954425
Name:FRUCHTER, LAZAR
Entity type:Individual
Prefix:
First Name:LAZAR
Middle Name:
Last Name:FRUCHTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1478 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-6602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:641 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12758
Practice Address - Country:US
Practice Address - Phone:917-430-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123563174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00974314Medicaid
NY60F572Medicare ID - Type Unspecified
NY00974314Medicaid