Healthcare Provider Details

I. General information

NPI: 1780621516
Provider Name (Legal Business Name): WYCKOFF FAMILY MEDICAL SERVICES P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 STOCKHOLM ST C/O FACULTY PRACTICE MANAGEMENT- SUITE 1-37 N
BROOKLYN NY
11237-4006
US

IV. Provider business mailing address

374 STOCKHOLM ST C/O FACULTY PRACTICE MANAGEMENT- SUITE 1-37 N
BROOKLYN NY
11237-4006
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-6485
  • Fax: 718-963-6793
Mailing address:
  • Phone: 718-963-6485
  • Fax: 718-963-6793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FARIDEH ZONOUZI-ZADEH
Title or Position: DIRECTOR/OFFICER
Credential: M.D.
Phone: 718-963-6485