Basic Information
| Provider Information | |||||||||
| NPI: | 1093923559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAKS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 W 116TH ST | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100262494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6464324600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13876 QUEENS BLVD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114352930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188506345 | ||||||||
| FaxNumber: | 7185594895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 203546 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 203546 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02349099 | 05 | NY | MEDICAID |