Healthcare Provider Details

I. General information

NPI: 1528607595
Provider Name (Legal Business Name): DAVID LYU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 WASHINGTON ST
BLOOMFIELD NJ
07003-3412
US

IV. Provider business mailing address

613 PARK AVE
EAST ORANGE NJ
07017-1905
US

V. Phone/Fax

Practice location:
  • Phone: 973-672-8573
  • Fax:
Mailing address:
  • Phone: 973-672-8573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MA12690500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7770004037881901
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier25MA12690500
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: