Healthcare Provider Details

I. General information

NPI: 1861649519
Provider Name (Legal Business Name): MUDGIL DERMATOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 5TH AVE APT 1D
NEW YORK NY
10011-8803
US

IV. Provider business mailing address

30 5TH AVE APT 1D
NEW YORK NY
10011-8803
US

V. Phone/Fax

Practice location:
  • Phone: 212-228-2526
  • Fax: 212-228-2735
Mailing address:
  • Phone: 212-228-2526
  • Fax: 212-228-2735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: ADARSH VIJAY MUDGIL
Title or Position: PRESIDENT
Credential: MD
Phone: 631-334-7786