Healthcare Provider Details

I. General information

NPI: 1598826729
Provider Name (Legal Business Name): MARIE-LOUISE FABIENNE DAGUILH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 FULTON AVE FL 3
BRONX NY
10456-3402
US

IV. Provider business mailing address

48 SILVER ST
ELMONT NY
11003-3621
US

V. Phone/Fax

Practice location:
  • Phone: 718-901-8749
  • Fax:
Mailing address:
  • Phone: 516-352-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number212529
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: