1881857761 NPI number — LYNNAE H DUFFALO MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881857761 NPI number — LYNNAE H DUFFALO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUFFALO
Provider First Name:
LYNNAE
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HYATT
Provider Other First Name:
LYNNAE
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881857761
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HYGEIA DR
Provider Second Line Business Mailing Address:
SUITE 2300
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-2049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-638-4860
Provider Business Mailing Address Fax Number:
617-536-8093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4745 OGLETOWN-STANTON ROAD
Provider Second Line Business Practice Location Address:
MAP 1, SUITE 220
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-638-4860
Provider Business Practice Location Address Fax Number:
617-536-8093
Provider Enumeration Date:
07/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD433919 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: MD433919 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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