Healthcare Provider Details

I. General information

NPI: 1407269590
Provider Name (Legal Business Name): YOLANDA STAHL DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1457 MERRICK AVE
MERRICK NY
11566
US

IV. Provider business mailing address

1457 MERRICK AVE
MERRICK NY
11566
US

V. Phone/Fax

Practice location:
  • Phone: 576-379-0815
  • Fax: 576-379-0872
Mailing address:
  • Phone: 576-379-0815
  • Fax: 576-379-0872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN0056720
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN005672
License Number StateNY

VIII. Authorized Official

Name: DR. YOLANDA STAHL
Title or Position: DOCTOR
Credential: DPM
Phone: 576-379-0815