Healthcare Provider Details

I. General information

NPI: 1326335068
Provider Name (Legal Business Name): EASTERN PEDIATRICS,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CANDLEWOOD PATH
DIX HILLS NY
11746
US

IV. Provider business mailing address

40 CANDLEWOOD PATH
DIX HILLS NY
11746-5306
US

V. Phone/Fax

Practice location:
  • Phone: 631-462-2240
  • Fax:
Mailing address:
  • Phone: 631-462-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number193569
License Number StateNY

VIII. Authorized Official

Name: MARYANN AGBIM
Title or Position: OFFICE MANAGER
Credential:
Phone: 631-462-2440