Healthcare Provider Details

I. General information

NPI: 1164899530
Provider Name (Legal Business Name): MRS. SAMANTHA MASTERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 AUSTIN ST SUITE 200
FOREST HILLS NY
11375-1022
US

IV. Provider business mailing address

3225 PLEASANT RIDGE RD
WINGDALE NY
12594-1420
US

V. Phone/Fax

Practice location:
  • Phone: 845-797-1239
  • Fax:
Mailing address:
  • Phone: 845-797-1239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number963874151
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: