Healthcare Provider Details

I. General information

NPI: 1194136317
Provider Name (Legal Business Name): SHIRLEY LOUIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2014
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 EASTCHESTER RD
BRONX NY
10461-2604
US

IV. Provider business mailing address

619 MATTELINE ST
UNIONDALE NY
11553-2618
US

V. Phone/Fax

Practice location:
  • Phone: 718-904-4032
  • Fax:
Mailing address:
  • Phone: 516-770-4094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301504515
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: