Healthcare Provider Details

I. General information

NPI: 1972588564
Provider Name (Legal Business Name): JOSEPH MICHAEL TIBALDI M.D.,F.A.C.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 04/30/2024
Certification Date: 04/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17415 HORACE HARDING EXPY FL 2
FRESH MEADOWS NY
11365-1527
US

IV. Provider business mailing address

17415 HORACE HARDING EXPY FL 2
FRESH MEADOWS NY
11365-1527
US

V. Phone/Fax

Practice location:
  • Phone: 718-762-3111
  • Fax: 718-353-6315
Mailing address:
  • Phone: 718-762-3111
  • Fax: 718-353-6315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number144862
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberAT1048188
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: