Healthcare Provider Details

I. General information

NPI: 1083610521
Provider Name (Legal Business Name): ADVANCED DERMATOLOGY OF NEW YORK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CENTRAL PARK S STE 107
NEW YORK NY
10019-1449
US

IV. Provider business mailing address

200 CENTRAL PARK S STE 107
NEW YORK NY
10019-1449
US

V. Phone/Fax

Practice location:
  • Phone: 212-262-2500
  • Fax: 212-246-0890
Mailing address:
  • Phone: 212-262-2500
  • Fax: 212-246-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

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