Healthcare Provider Details

I. General information

NPI: 1265618532
Provider Name (Legal Business Name): CHILDREN'S SKIN AND LASER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 ATLANTIC AVE GROUND FLOOR
BROOKLYN NY
11217-2143
US

IV. Provider business mailing address

440 ATLANTIC AVE GROUND FLOOR
BROOKLYN NY
11217-2143
US

V. Phone/Fax

Practice location:
  • Phone: 718-797-5504
  • Fax: 718-797-5645
Mailing address:
  • Phone: 718-797-5504
  • Fax: 718-797-5645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number226018
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number226018
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number226018
License Number StateNY

VIII. Authorized Official

Name: DR. SOURAB PATRICK CHOUDHURY
Title or Position: PRESIDENT
Credential: DO
Phone: 718-797-5504