Healthcare Provider Details

I. General information

NPI: 1902216229
Provider Name (Legal Business Name): LAURELTON MEDICAL PHYSICIANS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22414 MERRICK BLVD
LAURELTON NY
11413-2023
US

IV. Provider business mailing address

22414 MERRICK BLVD
LAURELTON NY
11413-2023
US

V. Phone/Fax

Practice location:
  • Phone: 718-949-6433
  • Fax: 718-949-0331
Mailing address:
  • Phone: 718-949-6433
  • Fax: 718-949-0331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number178587
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number178587
License Number StateNY

VIII. Authorized Official

Name: RICHARD WATSON
Title or Position: OWNER
Credential: MD
Phone: 718-949-6433