Healthcare Provider Details

I. General information

NPI: 1801954680
Provider Name (Legal Business Name): VALLEY STREAM MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 ALBERT CT
VALLEY STREAM NY
11580-4944
US

IV. Provider business mailing address

3 ALBERT CT
VALLEY STREAM NY
11580-4944
US

V. Phone/Fax

Practice location:
  • Phone: 516-285-5683
  • Fax:
Mailing address:
  • Phone: 516-285-5683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number207287
License Number StateNY

VIII. Authorized Official

Name: MORONKEJI FAGBEMI
Title or Position: DIRECTOR OFFICER
Credential:
Phone: 516-285-5683