Healthcare Provider Details

I. General information

NPI: 1386078236
Provider Name (Legal Business Name): ADVANCED DERMATOLOGY OF NEW YORK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CENTRAL PARK S SUITE 107
NEW YORK NY
10019-1436
US

IV. Provider business mailing address

200 CENTRAL PARK S SUITE 107
NEW YORK NY
10019-1436
US

V. Phone/Fax

Practice location:
  • Phone: 212-262-2500
  • Fax: 212-765-3210
Mailing address:
  • Phone: 212-262-2500
  • Fax: 212-765-3210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. LAWRENCE JAEGER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: D.O
Phone: 212-262-2500