Healthcare Provider Details

I. General information

NPI: 1013025345
Provider Name (Legal Business Name): MARTIN J. FINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 BROADWAY ROOM A1-9
ELMHURST NY
11373-1329
US

IV. Provider business mailing address

7901 BROADWAY ROOM A1-9
ELMHURST NY
11373-1329
US

V. Phone/Fax

Practice location:
  • Phone: 718-334-4952
  • Fax: 718-334-4815
Mailing address:
  • Phone: 718-334-4952
  • Fax: 718-334-4815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number171004
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01522132
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: