Healthcare Provider Details

I. General information

NPI: 1003495102
Provider Name (Legal Business Name): GEORGI LUKOSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 YORK AVE
NEW YORK NY
10021-3129
US

IV. Provider business mailing address

520 E 70TH ST
NEW YORK NY
10021-9800
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-5454
  • Fax:
Mailing address:
  • Phone: 212-746-2832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: