Healthcare Provider Details

I. General information

NPI: 1205805934
Provider Name (Legal Business Name): DOUGLAS J VANDER HEIDE MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 E 85TH ST APT G
NEW YORK NY
10028-0440
US

IV. Provider business mailing address

10 E 85TH ST 5A
NYC NY
10028-0412
US

V. Phone/Fax

Practice location:
  • Phone: 212-772-6443
  • Fax:
Mailing address:
  • Phone: 212-772-6443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number131230
License Number StateNY

VIII. Authorized Official

Name: DOUGLAS J VAN DER HEIDE
Title or Position: SOLE PROPRIETER
Credential:
Phone: 212-772-6443