Healthcare Provider Details

I. General information

NPI: 1013075779
Provider Name (Legal Business Name): DAVID CARMILI PHYSICIAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 SENECA AVE
RIDGEWOOD NY
11385-2895
US

IV. Provider business mailing address

714 SENECA AVE
RIDGEWOOD NY
11385-2895
US

V. Phone/Fax

Practice location:
  • Phone: 718-386-6663
  • Fax:
Mailing address:
  • Phone: 718-386-6663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number171109
License Number StateNY

VIII. Authorized Official

Name: DAVID CARMILI
Title or Position: DIRECTOR OFFICER
Credential:
Phone: 718-386-6663