Healthcare Provider Details

I. General information

NPI: 1003048448
Provider Name (Legal Business Name): WILBERT LAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2009
Last Update Date: 08/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 W 26TH ST SUITE 302
NEW YORK NY
10010-1006
US

IV. Provider business mailing address

1815 SUMMERFIELD ST APT A1
RIDGEWOOD NY
11385-5839
US

V. Phone/Fax

Practice location:
  • Phone: 718-285-0588
  • Fax: 718-285-9323
Mailing address:
  • Phone: 646-239-2756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070016725
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number030205-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: