1326216904 NPI number — DR. HOLLY KRISTIN YETTAW LUTS MD

Table of content: DR. HOLLY KRISTIN YETTAW LUTS MD (NPI 1326216904)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326216904 NPI number — DR. HOLLY KRISTIN YETTAW LUTS MD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
YETTAW LUTS

Provider First Name:
HOLLY

Provider Middle Name:
KRISTIN

Provider Name Prefix Text:
DR.

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:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326216904

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
04/21/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3332 ROCHAMBEAU AVE

Provider Second Line Business Mailing Address:
DEPT OF OB/GYN

Provider Business Mailing Address City Name:
BRONX

Provider Business Mailing Address State Name:
NY

Provider Business Mailing Address Postal Code:
10467-2836

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
718-920-5157

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3332 ROCHAMBEAU AVE

Provider Second Line Business Practice Location Address:
DEPT OF OB/GYN

Provider Business Practice Location Address City Name:
BRONX

Provider Business Practice Location Address State Name:
NY

Provider Business Practice Location Address Postal Code:
10467-2836

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
718-920-5157

Provider Business Practice Location Address Fax Number:
718-920-6313

Provider Enumeration Date:
02/15/2008

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: 207VX0000X , with the licence number: 4301508279 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 207V00000X , with the licence number: 2602561 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .