Healthcare Provider Details

I. General information

NPI: 1245822717
Provider Name (Legal Business Name): GARY LUONG MAOM, L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2021
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MADISON AVE RM 1102
NEW YORK NY
10022-5497
US

IV. Provider business mailing address

515 MADISON AVE RM 1102
NEW YORK NY
10022-5497
US

V. Phone/Fax

Practice location:
  • Phone: 347-762-6416
  • Fax:
Mailing address:
  • Phone: 347-762-6416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number006857
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: