Healthcare Provider Details

I. General information

NPI: 1336343268
Provider Name (Legal Business Name): METRO DERMATOLOGY OF NY,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14472 NORTHERN BLVD STE 203
FLUSHING NY
11354-4231
US

IV. Provider business mailing address

4012 80TH ST
ELMHURST NY
11373-1234
US

V. Phone/Fax

Practice location:
  • Phone: 718-886-9000
  • Fax: 718-961-0666
Mailing address:
  • Phone: 718-886-9000
  • Fax: 718-961-0666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number186672
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number258414
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012705
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number270019
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number191741
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012529
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number015855
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number017384
License Number StateNY
# 9
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number017273
License Number StateNY

VIII. Authorized Official

Name: HYUN SOO LEE
Title or Position: OWNER
Credential: MD
Phone: 718-886-9000