Healthcare Provider Details

I. General information

NPI: 1164500302
Provider Name (Legal Business Name): TONI M OTWAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TONI M OTWAY-GRANNUM MD

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1478 VICTORY BLVD
STATEN ISLAND NY
10301-3915
US

IV. Provider business mailing address

1478 VICTORY BLVD
STATEN ISLAND NY
10301-3915
US

V. Phone/Fax

Practice location:
  • Phone: 718-442-3434
  • Fax: 718-981-4578
Mailing address:
  • Phone: 718-442-3434
  • Fax: 718-981-4578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number216745
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: