Healthcare Provider Details

I. General information

NPI: 1487669883
Provider Name (Legal Business Name): HUNTINGTON DERMATOLOGY AND COSMETICS ASSOCIATE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 PROSPECT ST
HUNTINGTON NY
11743
US

IV. Provider business mailing address

11 PROSPECT ST
HUNTINGTON NY
11743
US

V. Phone/Fax

Practice location:
  • Phone: 631-424-3376
  • Fax: 631-424-0199
Mailing address:
  • Phone: 631-424-3376
  • Fax: 631-424-0199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number152208
License Number StateNY

VIII. Authorized Official

Name: DR. PHYLLIS J SMITH
Title or Position: OWNER
Credential:
Phone: 631-424-3376