Healthcare Provider Details

I. General information

NPI: 1801954425
Provider Name (Legal Business Name): LAZAR FRUCHTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 KNICKERBOCKER RD
LIVINGSTON NY
12758
US

IV. Provider business mailing address

1478 E 15TH ST
BROOKLYN NY
11230-6602
US

V. Phone/Fax

Practice location:
  • Phone: 917-430-0280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number123563
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: