Healthcare Provider Details

I. General information

NPI: 1407430655
Provider Name (Legal Business Name): NEW PRESTON DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 E SHORE RD
NEW PRESTON CT
06777-1628
US

IV. Provider business mailing address

18 E SHORE RD
NEW PRESTON CT
06777-1628
US

V. Phone/Fax

Practice location:
  • Phone: 484-868-9998
  • Fax: 860-393-1079
Mailing address:
  • Phone: 484-868-9998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREAS BOKER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 917-902-0540