MEDICARE: PARK AVENUE DERMATOLOGY & PLASTIC SURGERY LLP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	207ND0101X	MOHS-Micrographic Surgery Physician	NY
2	207NS0135X	Procedural Dermatology Physician	NY
3	208200000X	Plastic Surgery Physician	NY

General Provider Information

NPI Number	:	1659373025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK AVENUE DERMATOLOGY & PLASTIC SURGERY LLP

Provider Business Mailing Address
First Line	:	625 PARK AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-6545
Country	:	US
Telephone Number	:	212-794-4000
Fax Number	:	212-794-0231

Provider Business Practice Location Address
First Line	:	625 PARK AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-6545
Country	:	US
Telephone Number	:	212-794-4000
Fax Number	:	212-794-0231

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. ROBERT H GOTKIN
Credential	:	MD
Telephone Number	:	212-794-4000

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	09/11/2025

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