Healthcare Provider Details

I. General information

NPI: 1023373792
Provider Name (Legal Business Name): VIRGINIA DIFEDE MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 EXECUTIVE DR SUITE LL 105/108
PLAINVIEW NY
11803-6604
US

IV. Provider business mailing address

26 HIGHVIEW LN
RIDGE NY
11961-2111
US

V. Phone/Fax

Practice location:
  • Phone: 516-576-2040
  • Fax: 516-576-2131
Mailing address:
  • Phone: 631-740-4097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2347
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: