Healthcare Provider Details

I. General information

NPI: 1205286341
Provider Name (Legal Business Name): M GOLDIS MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 QUENTIN RD FL 2 SUITE D
BROOKLYN NY
11223-1102
US

IV. Provider business mailing address

1777 OCEAN PKWY APT 502
BROOKLYN NY
11223-2054
US

V. Phone/Fax

Practice location:
  • Phone: 347-462-9292
  • Fax: 646-393-5500
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number266491
License Number StateNY

VIII. Authorized Official

Name: MARINA ELLI GOLDIS
Title or Position: DOCTOR
Credential: M.D.
Phone: 347-462-9292