Healthcare Provider Details

I. General information

NPI: 1255343281
Provider Name (Legal Business Name): DOUGLAS MICHAEL LUXENBERG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PT WASHINGTON BLVD
ROSLYN NY
11576
US

IV. Provider business mailing address

100 PORT WASHINGTON BLVD SUITE 108
ROSLYN NY
11576-1347
US

V. Phone/Fax

Practice location:
  • Phone: 516-365-3340
  • Fax: 516-365-5512
Mailing address:
  • Phone: 516-365-3340
  • Fax: 516-365-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number240697
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: