Healthcare Provider Details

I. General information

NPI: 1376712356
Provider Name (Legal Business Name): HOWARD BRADNOCK MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19616 HILLSIDE AVE
HOLLIS NY
11423-2125
US

IV. Provider business mailing address

19616 HILLSIDE AVE
HOLLIS NY
11423-2125
US

V. Phone/Fax

Practice location:
  • Phone: 718-217-6806
  • Fax: 718-217-0339
Mailing address:
  • Phone: 718-217-6806
  • Fax: 718-217-0339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number181072
License Number StateNY

VIII. Authorized Official

Name: HOWARD W BRADNOCK
Title or Position: PRESIDENT
Credential: MD
Phone: 718-217-6806