Healthcare Provider Details

I. General information

NPI: 1629054754
Provider Name (Legal Business Name): WENDY WEI-YUE LOU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 04/14/2021
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W CARVER ST STE 2
HUNTINGTON NY
11743-3303
US

IV. Provider business mailing address

200 W CARVER ST STE 2
HUNTINGTON NY
11743-3303
US

V. Phone/Fax

Practice location:
  • Phone: 631-424-3376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number200826
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number200826
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number200826
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: