=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679809354
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS LUTRI THOMAS LUTRI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2009
-----------------------------------------------------
Last Update Date | 10/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 WATERSIDE PLZ SUITE A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-842-0226
-----------------------------------------------------
Fax | 212-685-1792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 WATERSIDE PLZ SUITE A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-842-0226
-----------------------------------------------------
Fax | 212-685-1792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 157017
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------