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General NPI Number Information
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NPI Number | 1447642103
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Entity Type | Organization
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Legal Business Name | PARK AVENUE DERMATOLOGY
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Dates
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Enumeration Date | 03/04/2015
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Last Update Date | 03/04/2015
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Provider Practice Location Address
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Address Line | 31 TIOGA ST
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City | STATEN ISLAND
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State | NY
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Zip | 10301
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Country | US
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Telephone | 718-981-5040
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Fax |
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Provider Business Mailing Address
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Address Line | 31 TIOGA ST
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City | STATEN ISLAND
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State | NY
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Zip | 10301
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Country | US
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Telephone | 718-981-5040
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Fax |
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Authorized Official
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Title or Position | OFICE MANAGER
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Name | AMANDA DICK
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Credential |
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Telephone | 718-981-5040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number | 018032
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License Number State | NY
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