Healthcare Provider Details

I. General information

NPI: 1720565187
Provider Name (Legal Business Name): BAYSIDE PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4223 212TH ST STE 1A
BAYSIDE NY
11361-2987
US

IV. Provider business mailing address

4223 212TH ST STE 1A
BAYSIDE NY
11361-2987
US

V. Phone/Fax

Practice location:
  • Phone: 718-229-7337
  • Fax: 718-229-7333
Mailing address:
  • Phone: 718-229-7337
  • Fax: 718-229-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: YOHAN PARK
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 718-229-7337