Healthcare Provider Details

I. General information

NPI: 1023523602
Provider Name (Legal Business Name): PAGODA MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 LAKE AVE FL 1
STATEN ISLAND NY
10303-2640
US

IV. Provider business mailing address

399 LAKE AVE FL 1
STATEN ISLAND NY
10303-2640
US

V. Phone/Fax

Practice location:
  • Phone: 732-205-1707
  • Fax:
Mailing address:
  • Phone: 347-933-9089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number275175
License Number StateNY

VIII. Authorized Official

Name: ANATOLY SHNAYDER
Title or Position: MD
Credential:
Phone: 347-933-9089