Healthcare Provider Details

I. General information

NPI: 1609980846
Provider Name (Legal Business Name): MMC DIVISION OF BREAST SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 64TH ST STE 1
BROOKLYN NY
11220-4753
US

IV. Provider business mailing address

6300 8TH AVE
BROOKLYN NY
11220-4718
US

V. Phone/Fax

Practice location:
  • Phone: 718-765-2570
  • Fax: 718-765-2569
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARUSHEELA ANDAZ
Title or Position: DEPARTMENT HEAD
Credential: MD
Phone: 718-283-8773