Healthcare Provider Details

I. General information

NPI: 1568609568
Provider Name (Legal Business Name): IRONDEQUOIT PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 TITUS AVE STE F
ROCHESTER NY
14617-3544
US

IV. Provider business mailing address

485 TITUS AVE STE F
ROCHESTER NY
14617-3544
US

V. Phone/Fax

Practice location:
  • Phone: 585-266-0310
  • Fax: 585-266-9207
Mailing address:
  • Phone: 585-266-0310
  • Fax: 585-266-9207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW D HOLT
Title or Position: SOLE PROPRIETOR
Credential: MD
Phone: 585-266-0310