Healthcare Provider Details

I. General information

NPI: 1598121162
Provider Name (Legal Business Name): ELDERDERM DERMATOLOGY SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10311 68TH DR
FOREST HILLS NY
11375-3159
US

IV. Provider business mailing address

10311 68TH DR
FOREST HILLS NY
11375-3159
US

V. Phone/Fax

Practice location:
  • Phone: 917-309-3881
  • Fax:
Mailing address:
  • Phone: 917-309-3881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFERY MITCHELL WEINBERG
Title or Position: PRESIDENT
Credential: MD
Phone: 917-309-3881