Healthcare Provider Details

I. General information

NPI: 1982637898
Provider Name (Legal Business Name): PETERIS E DZENIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 MAIN ST
FLUSHING NY
11355-5050
US

IV. Provider business mailing address

5510 MAIN ST
FLUSHING NY
11355-5050
US

V. Phone/Fax

Practice location:
  • Phone: 718-463-9220
  • Fax: 718-463-9214
Mailing address:
  • Phone: 718-463-9220
  • Fax: 718-463-9214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number154791-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: