Healthcare Provider Details

I. General information

NPI: 1316996937
Provider Name (Legal Business Name): ISLAND DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 E PARK AVE
LONG BEACH NY
11561-2505
US

IV. Provider business mailing address

604 E PARK AVE
LONG BEACH NY
11561-2505
US

V. Phone/Fax

Practice location:
  • Phone: 516-432-0011
  • Fax: 516-432-1686
Mailing address:
  • Phone: 516-432-0011
  • Fax: 516-432-1686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD HARLAN FALCON
Title or Position: PRESIDENT
Credential: MD
Phone: 516-432-0011