Healthcare Provider Details

I. General information

NPI: 1356071526
Provider Name (Legal Business Name): FOUR CORNERS MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2022
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14314 LAKEWOOD AVE
JAMAICA NY
11435-5408
US

IV. Provider business mailing address

14314 LAKEWOOD AVE
JAMAICA NY
11435-5408
US

V. Phone/Fax

Practice location:
  • Phone: 347-466-3605
  • Fax:
Mailing address:
  • Phone: 347-466-3605
  • Fax: 347-317-7895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LILIIA VLADOV
Title or Position: MANAGER
Credential:
Phone: 347-466-3605