Healthcare Provider Details

I. General information

NPI: 1093782492
Provider Name (Legal Business Name): SOHO SKIN AND LASER DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 GRAND ST STE 3E
NEW YORK NY
10013-3859
US

IV. Provider business mailing address

347 MOUNT PLEASANT AVE STE 205
WEST ORANGE NJ
07052-2749
US

V. Phone/Fax

Practice location:
  • Phone: 212-431-7600
  • Fax: 212-431-7521
Mailing address:
  • Phone: 973-571-2121
  • Fax: 973-498-0569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberNY165531
License Number StateNY

VIII. Authorized Official

Name: DR. SIMON SAMAHA
Title or Position: CEO
Credential: M.D.
Phone: 973-571-2121