Healthcare Provider Details

I. General information

NPI: 1447642103
Provider Name (Legal Business Name): PARK AVENUE DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 TIOGA ST
STATEN ISLAND NY
10301
US

IV. Provider business mailing address

31 TIOGA ST
STATEN ISLAND NY
10301
US

V. Phone/Fax

Practice location:
  • Phone: 718-981-5040
  • Fax:
Mailing address:
  • Phone: 718-981-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number018032
License Number StateNY

VIII. Authorized Official

Name: AMANDA DICK
Title or Position: OFICE MANAGER
Credential:
Phone: 718-981-5040