Healthcare Provider Details

I. General information

NPI: 1134560121
Provider Name (Legal Business Name): AVERY H. MALTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24302 NORTHERN BLVD
DOUGLASTON NY
11362-1150
US

IV. Provider business mailing address

22071 67TH AVE
BAYSIDE NY
11364-2637
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-6200
  • Fax:
Mailing address:
  • Phone: 718-631-1698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: