Healthcare Provider Details

I. General information

NPI: 1225440068
Provider Name (Legal Business Name): AVENUE U MEDICAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2153 E 3RD ST
BROOKLYN NY
11223-4030
US

IV. Provider business mailing address

2153 E 3RD ST
BROOKLYN NY
11223-4030
US

V. Phone/Fax

Practice location:
  • Phone: 718-339-4607
  • Fax:
Mailing address:
  • Phone: 718-339-4607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: VICTOR FARIWA
Title or Position: PROVIDER
Credential: M.D.
Phone: 718-934-9720