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General NPI Number Information
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NPI Number | 1184661290
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Entity Type | Organization
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Legal Business Name | THE SHIELD OF DAVID, INC.
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Dates
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Enumeration Date | 05/31/2006
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Last Update Date | 04/24/2018
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Provider Practice Location Address
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Address Line | 3909 214TH PL
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City | BAYSIDE
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State | NY
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Zip | 11361-2123
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Country | US
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Telephone | 718-269-2004
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Fax |
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Provider Business Mailing Address
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Address Line | 144-61 ROOSEVELT AVENUE
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City | FLUSHING
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State | NY
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Zip | 11354
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. SUSAN PROVENZANO
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Credential |
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Telephone | 718-886-1682
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 6593164
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License Number State | NY
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