Healthcare Provider Details

I. General information

NPI: 1578613600
Provider Name (Legal Business Name): JUDITH ANN HENDRICKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 RICHMOND ROAD
STATEN ISLAND NY
10306
US

IV. Provider business mailing address

1870 RICHMOND ROAD
STATEN ISLAND NY
10306
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-5400
  • Fax: 718-980-6012
Mailing address:
  • Phone: 718-667-5400
  • Fax: 718-980-6012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number127469
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: