Healthcare Provider Details

I. General information

NPI: 1457550352
Provider Name (Legal Business Name): WAINWRIGHT DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 NORTH SALEM ROAD 2ND FLOOR
CROSS RIVER NY
10518-0365
US

IV. Provider business mailing address

PO BOX 365
CROSS RIVER NY
10518-0365
US

V. Phone/Fax

Practice location:
  • Phone: 914-763-3000
  • Fax: 718-518-8616
Mailing address:
  • Phone: 914-763-3000
  • Fax: 718-518-8616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number234018
License Number StateNY

VIII. Authorized Official

Name: DR. BRENT WAINWRIGHT
Title or Position: PRICIPAL PHYSICIAN - ONE MEMBER LLC
Credential: MD
Phone: 914-763-3000