Healthcare Provider Details

I. General information

NPI: 1578065249
Provider Name (Legal Business Name): MSAN MEDICAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6861 FRESH POND RD
RIDGEWOOD NY
11385-5263
US

IV. Provider business mailing address

6861 FRESH POND RD
RIDGEWOOD NY
11385-5263
US

V. Phone/Fax

Practice location:
  • Phone: 718-576-3354
  • Fax: 715-576-3505
Mailing address:
  • Phone: 718-576-3354
  • Fax: 715-576-3505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number231830
License Number StateNY

VIII. Authorized Official

Name: MYAT SAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 718-576-3354