Healthcare Provider Details

I. General information

NPI: 1023000353
Provider Name (Legal Business Name): DAVID C COLLYMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 CLAY AVE
BRONX NY
10457-7239
US

IV. Provider business mailing address

1776 CLAY AVE
BRONX NY
10457-7239
US

V. Phone/Fax

Practice location:
  • Phone: 718-299-1100
  • Fax: 718-299-4633
Mailing address:
  • Phone: 718-299-1100
  • Fax: 718-299-4633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number225742
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: