Healthcare Provider Details

I. General information

NPI: 1376329995
Provider Name (Legal Business Name): SUMAKMUR HOLIWELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6315 ROOSEVELT AVE
WOODSIDE NY
11377-3641
US

IV. Provider business mailing address

6315 ROOSEVELT AVE
WOODSIDE NY
11377-3641
US

V. Phone/Fax

Practice location:
  • Phone: 718-874-3173
  • Fax:
Mailing address:
  • Phone: 718-874-3173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number034583
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: