Healthcare Provider Details

I. General information

NPI: 1487792024
Provider Name (Legal Business Name): ISLAND KIDS PEDIATRICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2007
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2066 RICHMOND AVENUE 1ST FLOOR
STATEN ISLAND NY
10314-3916
US

IV. Provider business mailing address

2066 RICHMOND AVENUE 1ST FLOOR
STATEN ISLAND NY
10314-3916
US

V. Phone/Fax

Practice location:
  • Phone: 718-982-9001
  • Fax: 718-982-9008
Mailing address:
  • Phone: 718-982-9001
  • Fax: 718-982-9008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number200270
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number200270
License Number StateNY

VIII. Authorized Official

Name: MR. DENIZ CEREB
Title or Position: PRESIDENT
Credential: M.D.
Phone: 718-982-9001