Healthcare Provider Details

I. General information

NPI: 1609328202
Provider Name (Legal Business Name): ALL STAR PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2016
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 STOWE RD STE 11
PEEKSKILL NY
10566-2582
US

IV. Provider business mailing address

2 STOWE RD STE 11
PEEKSKILL NY
10566-2582
US

V. Phone/Fax

Practice location:
  • Phone: 914-737-4222
  • Fax:
Mailing address:
  • Phone: 914-737-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number258602
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02817105
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: AZZA ABDEL-HAMID ABO-DEEB
Title or Position: OWNER
Credential: MD
Phone: 914-737-4222