Healthcare Provider Details

I. General information

NPI: 1003952235
Provider Name (Legal Business Name): PEDIATRIC HEALTHCARE OF QUEENS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 02/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 47 CRESCENT STREET SUITE 101
ASTORIA NY
11102
US

IV. Provider business mailing address

3014 37TH ST
ASTORIA NY
11103-3809
US

V. Phone/Fax

Practice location:
  • Phone: 718-278-9500
  • Fax: 718-278-2430
Mailing address:
  • Phone: 718-278-9500
  • Fax: 718-278-2430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number170828
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number170828
License Number State

VIII. Authorized Official

Name: DR. DEMETRIOS MARKOUIZOS
Title or Position: PRESIDENT OWNER
Credential: MD
Phone: 718-278-9500