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General NPI Number Information
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NPI Number | 1003287343
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Entity Type | Organization
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Legal Business Name | WOODSIDE MEDICAL CARE
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Dates
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Enumeration Date | 10/13/2015
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Last Update Date | 12/27/2018
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Provider Practice Location Address
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Address Line | 6019 ROOSEVELT AVE STE 201
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City | WOODSIDE
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State | NY
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Zip | 11377-3537
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Country | US
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Telephone | 718-446-6579
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Fax | 718-446-1213
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Provider Business Mailing Address
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Address Line | 6019 ROOSEVELT AVE STE 201
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City | WOODSIDE
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State | NY
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Zip | 11377-3537
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Country | US
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Telephone | 718-446-6579
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Fax | 718-446-1213
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DANIEL PARK
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Credential | D.O
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Telephone | 718-446-6579
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 209387
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License Number State | NY
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