Basic Information
| Provider Information | |||||||||
| NPI: | 1205409828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREYSON | ||||||||
| FirstName: | LUKAS | ||||||||
| MiddleName: | MAVERICK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 WYCKOFF ST APT 4 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112016345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175864563 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 275 7TH AVE FL 12 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100016756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126041730 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2021 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.