Healthcare Provider Details

I. General information

NPI: 1750410759
Provider Name (Legal Business Name): IRA DAVIS, MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627 HYLAN BLVD # C BOX 10
STATEN ISLAND NY
10314
US

IV. Provider business mailing address

280 N CENTRAL AVE SUITE 114
HARTSDALE NY
10530-1832
US

V. Phone/Fax

Practice location:
  • Phone: 718-477-4022
  • Fax: 718-698-9573
Mailing address:
  • Phone: 914-288-0500
  • Fax: 914-288-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number182268
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number182268
License Number StateNY

VIII. Authorized Official

Name: MRS. WENDY MANN
Title or Position: BILLER
Credential:
Phone: 914-774-2478