Healthcare Provider Details

I. General information

NPI: 1851746952
Provider Name (Legal Business Name): MEDIJE MASHKULLI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 04/05/2020
Certification Date: 04/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-8855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number300289
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: