Healthcare Provider Details

I. General information

NPI: 1154408300
Provider Name (Legal Business Name): LIBERTY PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 OLD MONTICELLO RD CATSKILL PROF PLAZA
FERNDALE NY
12754
US

IV. Provider business mailing address

39 OLD MONTICELLO RD
FERNDALE NY
12754
US

V. Phone/Fax

Practice location:
  • Phone: 845-292-6684
  • Fax: 845-292-6770
Mailing address:
  • Phone: 845-292-6684
  • Fax: 845-292-6770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberNY178764
License Number StateNY

VIII. Authorized Official

Name: DARSHAN G TRIVEDI
Title or Position: PHYSICIAN OWNER
Credential:
Phone: 845-292-6684