Healthcare Provider Details

I. General information

NPI: 1710361902
Provider Name (Legal Business Name): LAUREN ANN KUCHMAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN ANN KUCHMAK MD

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COMMUNITY DR
MANHASSET NY
11030
US

IV. Provider business mailing address

1001 W MAIN ST SUITE B
FREEHOLD NJ
07728-2579
US

V. Phone/Fax

Practice location:
  • Phone: 516-562-0100
  • Fax:
Mailing address:
  • Phone: 732-294-2540
  • Fax: 732-409-2621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number294657-1
License Number StateNY

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: