Healthcare Provider Details

I. General information

NPI: 1295239473
Provider Name (Legal Business Name): POPPY ADDISON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MASON AVE FL 3
STATEN ISLAND NY
10305-3408
US

IV. Provider business mailing address

256 MASON AVE FL 3
STATEN ISLAND NY
10305-3408
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-6398
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number73768
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number333393
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: