MEDICARE: ISLAND MEDICAL LASER, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083P0901X	Public Health & General Preventive Medicine Physician

General Provider Information

NPI Number	:	1144786914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND MEDICAL LASER, P.C.

Provider Business Mailing Address
First Line	:	425 BROADHOLLOW RD STE 427
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-4701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 GLEN COVE RD
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-1718
Country	:	US
Telephone Number	:	718-554-1042
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	MR. VARUN BAJAJ
Credential	:
Telephone Number	:	718-554-1042

Provider Enumeration Date	:	02/15/2019
Last Update Date	:	02/15/2019

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