Healthcare Provider Details

I. General information

NPI: 1790483741
Provider Name (Legal Business Name): MICHAEL INDIG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MAIMONIDES MEDICAL CENTER 4802 10TH AVENUE
BROOKLYN NY
11219
US

IV. Provider business mailing address

1250 E 22ND ST
BROOKLYN NY
11210-4515
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-6000
  • Fax:
Mailing address:
  • Phone: 347-502-8478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number063982
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: