Healthcare Provider Details

I. General information

NPI: 1023160504
Provider Name (Legal Business Name): ANDREW EDWARD SKODOL II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 RIVERSIDE DR BOX 129
NEW YORK NY
10032-1007
US

IV. Provider business mailing address

20 ELLIOT RD
GREAT NECK NY
11021-1520
US

V. Phone/Fax

Practice location:
  • Phone: 212-543-6247
  • Fax:
Mailing address:
  • Phone: 516-487-4314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number112809
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: