Healthcare Provider Details

I. General information

NPI: 1629736509
Provider Name (Legal Business Name): DERMATOLOGY & MOHS SURGERY OF LONG ISLAND, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NORTHERN BLVD STE 140
GREAT NECK NY
11021-5312
US

IV. Provider business mailing address

1000 NORTHERN BLVD STE 140
GREAT NECK NY
11021-5312
US

V. Phone/Fax

Practice location:
  • Phone: 516-808-4098
  • Fax: 888-351-6291
Mailing address:
  • Phone: 516-846-3300
  • Fax: 516-846-3305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSHUA FARHADIAN
Title or Position: OWNER
Credential: MD
Phone: 516-846-3300