Healthcare Provider Details

I. General information

NPI: 1174549737
Provider Name (Legal Business Name): DARA MATSEOANE-PETERSSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5141 BROADWAY
NEW YORK NY
10034-1159
US

IV. Provider business mailing address

622 W 168TH ST
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-4098
  • Fax: 212-305-4098
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number221332-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: