Healthcare Provider Details

I. General information

NPI: 1093790800
Provider Name (Legal Business Name): DOUGLAS LAX DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 MERRICK RD SUITE 304
ROCKVILLE CENTRE NY
11570-5254
US

IV. Provider business mailing address

242 MERRICK RD SUITE 304
ROCKVILLE CENTRE NY
11570-5254
US

V. Phone/Fax

Practice location:
  • Phone: 516-764-7070
  • Fax: 516-764-7073
Mailing address:
  • Phone: 516-764-7070
  • Fax: 516-764-7073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number158526
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: