Healthcare Provider Details

I. General information

NPI: 1326216904
Provider Name (Legal Business Name): HOLLY KRISTIN YETTAW LUTS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3332 ROCHAMBEAU AVE DEPT OF OB/GYN
BRONX NY
10467-2836
US

IV. Provider business mailing address

3332 ROCHAMBEAU AVE DEPT OF OB/GYN
BRONX NY
10467-2836
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-5157
  • Fax: 718-920-6313
Mailing address:
  • Phone: 718-920-5157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number4301508279
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2602561
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: