Healthcare Provider Details

I. General information

NPI: 1225105513
Provider Name (Legal Business Name): JOSEPH IWANICKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 06/15/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2792 OCEAN AVE FL 2
BROOKLYN NY
11229-4731
US

IV. Provider business mailing address

2792 OCEAN AVE FL 2
BROOKLYN NY
11229-4731
US

V. Phone/Fax

Practice location:
  • Phone: 833-635-2566
  • Fax: 833-635-2566
Mailing address:
  • Phone: 833-635-2566
  • Fax: 833-635-2566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number157144
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: