Healthcare Provider Details

I. General information

NPI: 1760265540
Provider Name (Legal Business Name): LUMINESCENCE MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 TROY SCHENECTADY ROAD BUILDING #2
LATHAM NY
12110
US

IV. Provider business mailing address

1202 TROY SCHENECTADY RAOD BUILDING #2
LATHAM NY
12110
US

V. Phone/Fax

Practice location:
  • Phone: 518-389-6100
  • Fax:
Mailing address:
  • Phone: 518-389-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PRAJESH GHIMIRE
Title or Position: PARTNER/PHYSICIAN
Credential: MD
Phone: 518-330-2843