Healthcare Provider Details

I. General information

NPI: 1669456984
Provider Name (Legal Business Name): I M PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6412 FRESH POND RD
RIDGEWOOD NY
11385-3331
US

IV. Provider business mailing address

6412 FRESH POND RD
RIDGEWOOD NY
11385-3331
US

V. Phone/Fax

Practice location:
  • Phone: 718-497-1565
  • Fax: 718-497-1567
Mailing address:
  • Phone: 718-497-1565
  • Fax: 718-497-1567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number217951
License Number StateNY

VIII. Authorized Official

Name: DR. IWONA KATARZYNA MIENKO
Title or Position: PRESIDENT
Credential: MD
Phone: 718-497-1565