Healthcare Provider Details

I. General information

NPI: 1801186861
Provider Name (Legal Business Name): TIMOTHY ROBERT KREIDER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7559 263RD ST
GLEN OAKS NY
11004-1150
US

IV. Provider business mailing address

7559 263RD ST
GLEN OAKS NY
11004-1150
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-8303
  • Fax: 718-470-1905
Mailing address:
  • Phone: 718-470-8303
  • Fax: 718-470-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT198793
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMT198793
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number275230-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: