Healthcare Provider Details

I. General information

NPI: 1003503392
Provider Name (Legal Business Name): HAVEN FAMILY MEDICINE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W 171ST ST STE W
NEW YORK NY
10032-2811
US

IV. Provider business mailing address

707 W 171ST ST STE W
NEW YORK NY
10032-2811
US

V. Phone/Fax

Practice location:
  • Phone: 212-927-3232
  • Fax: 212-927-4571
Mailing address:
  • Phone: 212-927-3232
  • Fax: 212-927-4571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO MORAN
Title or Position: OWNER
Credential: MD
Phone: 718-902-2244