Healthcare Provider Details

I. General information

NPI: 1720046857
Provider Name (Legal Business Name): DAMIAN J HAVRILIAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 10/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 EXECUTIVE BLVD SUITE 400
SUFFERN NY
10901-4164
US

IV. Provider business mailing address

2 EXECUTIVE BLVD SUITE 400
SUFFERN NY
10901-4164
US

V. Phone/Fax

Practice location:
  • Phone: 845-357-6202
  • Fax: 845-357-6239
Mailing address:
  • Phone: 845-357-6202
  • Fax: 845-357-6239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number175798
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number25MA0638500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: