Healthcare Provider Details

I. General information

NPI: 1275503021
Provider Name (Legal Business Name): DR. ROBERT M MOLDWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 76TH AVE
NEW HYDE PARK NY
11040-1433
US

IV. Provider business mailing address

175 COMMUNITY DR
GREAT NECK NY
11021-5502
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-7334
  • Fax:
Mailing address:
  • Phone: 516-465-1900
  • Fax: 516-465-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number169519
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number169519
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: