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General NPI Number Information
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NPI Number | 1356071526
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Entity Type | Organization
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Legal Business Name | FOUR CORNERS MEDICAL PC
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Dates
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Enumeration Date | 06/12/2022
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Last Update Date | 05/21/2025
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Provider Practice Location Address
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Address Line | 11622 METROPOLITAN AVE
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City | RICHMOND HILL
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State | NY
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Zip | 11418-1017
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Country | US
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Telephone | 347-466-3605
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Fax | 347-317-7895
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Provider Business Mailing Address
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Address Line | 7907 METROPOLITAN AVE
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City | MIDDLE VILLAGE
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State | NY
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Zip | 11379-2930
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Country | US
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Telephone | 347-466-3605
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Fax | 347-317-7895
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Authorized Official
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Title or Position | OWNER
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Name | JEAN-YVES DASTAIN
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Credential | MD
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Telephone | 347-466-3605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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