Healthcare Provider Details

I. General information

NPI: 1467978544
Provider Name (Legal Business Name): JAMES JOHN URBAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11404 BEACH CHANNEL DR
ROCKAWAY PARK NY
11694-2211
US

IV. Provider business mailing address

125 BEACH 124TH ST APT 4H
ROCKAWAY PARK NY
11694-1859
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-5555
  • Fax:
Mailing address:
  • Phone: 646-467-0508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: