Healthcare Provider Details

I. General information

NPI: 1720159106
Provider Name (Legal Business Name): PAMELA M DEFOREST MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTENNIAL WOMEN'S CENTER 3332 ROCHAMBEAU AVENUE
BRONX NY
10467
US

IV. Provider business mailing address

3673 MARCY ST
MOHEGAN LAKE NY
10547-1055
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-5157
  • Fax:
Mailing address:
  • Phone: 718-920-5157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number195044
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: