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General NPI Number Information
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NPI Number | 1447543913
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Entity Type | Organization
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Legal Business Name | LAKE GROVE PEDIATRICS, PC
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Dates
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Enumeration Date | 05/17/2011
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Last Update Date | 05/17/2011
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Provider Practice Location Address
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Address Line | 2233 NESCONSET HWY SUITE 106
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City | LAKE GROVE
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State | NY
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Zip | 11755-1000
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Country | US
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Telephone | 631-585-4440
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Fax |
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Provider Business Mailing Address
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Address Line | 2233 NESCONSET HWY SUITE 106
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City | LAKE GROVE
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State | NY
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Zip | 11755-1000
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Country | US
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Telephone | 631-585-4440
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. AMY DAWN GOLDBERG
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Credential | M.D.
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Telephone | 63158544400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 225178
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License Number State | NY
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