Healthcare Provider Details

I. General information

NPI: 1023101623
Provider Name (Legal Business Name): MICHAEL SCANLON D.P.M.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 CHURCH AVENUE
BROOKLYN NY
11218
US

IV. Provider business mailing address

408 CHURCH AVENUE
BROOKLYN NY
11218
US

V. Phone/Fax

Practice location:
  • Phone: 718-633-3074
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberN002978
License Number StateNY

VIII. Authorized Official

Name: MICHAEL SCANLON
Title or Position: SOLE PROPRIETER
Credential:
Phone: 718-633-3074