Healthcare Provider Details

I. General information

NPI: 1316974306
Provider Name (Legal Business Name): TELLY LIM DEMESA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CUMBERLAND DIAGNOSTIC & TREATMENT CENTER 100 NORTH PORTLAND AVENUE
BROOKLYN NY
11205
US

IV. Provider business mailing address

34 CROAK AVE
STATEN ISLAND NY
10314-5638
US

V. Phone/Fax

Practice location:
  • Phone: 718-260-7895
  • Fax: 718-260-7636
Mailing address:
  • Phone: 718-260-7759
  • Fax: 718-983-1840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number150826
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: