Healthcare Provider Details

I. General information

NPI: 1215095930
Provider Name (Legal Business Name): EASTSIDE MEDICAL OFFICE , PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 E 116TH ST
NEW YORK NY
10029-1147
US

IV. Provider business mailing address

3117 41ST ST
ASTORIA NY
11103-3901
US

V. Phone/Fax

Practice location:
  • Phone: 212-876-9700
  • Fax: 212-876-5745
Mailing address:
  • Phone: 718-278-5100
  • Fax: 718-278-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number214914
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number198749
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number136246
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number176228
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number205570
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number230776
License Number StateNY

VIII. Authorized Official

Name: ZAW MIN OO
Title or Position: PRESIDENT
Credential: M.D
Phone: 212-876-9700