Healthcare Provider Details

I. General information

NPI: 1437139227
Provider Name (Legal Business Name): AMIR MIODOVNIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 E 13TH ST 3F
NEW YORK NY
10003-4471
US

IV. Provider business mailing address

20 E 13TH ST 3F
NEW YORK NY
10003-4471
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-5756
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-109714
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number249904
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: