Healthcare Provider Details

I. General information

NPI: 1215378369
Provider Name (Legal Business Name): ELAN LURIA GOLDWASER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 03/22/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

693 WHITE PLAINS RD
SCARSDALE NY
10709
US

IV. Provider business mailing address

622 W 168TH ST PH 11
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 914-787-3292
  • Fax: 212-304-7050
Mailing address:
  • Phone: 212-305-9137
  • Fax: 212-304-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number289782
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: