Healthcare Provider Details

I. General information

NPI: 1164803284
Provider Name (Legal Business Name): SAM CHUAN LU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number25MA10330200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD61228859
License Number StateWA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: