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General NPI Number Information
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NPI Number | 1457550352
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Entity Type | Organization
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Legal Business Name | WAINWRIGHT DERMATOLOGY, PLLC
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Dates
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Enumeration Date | 07/12/2007
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Last Update Date | 01/23/2012
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Provider Practice Location Address
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Address Line | 19 NORTH SALEM ROAD 2ND FLOOR
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City | CROSS RIVER
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State | NY
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Zip | 10518-0365
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Country | US
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Telephone | 914-763-3000
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Fax | 718-518-8616
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Provider Business Mailing Address
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Address Line | PO BOX 365
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City | CROSS RIVER
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State | NY
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Zip | 10518-0365
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Country | US
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Telephone | 914-763-3000
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Fax | 718-518-8616
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Authorized Official
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Title or Position | PRICIPAL PHYSICIAN - ONE MEMBER LLC
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Name | DR. BRENT WAINWRIGHT
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Credential | MD
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Telephone | 914-763-3000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 234018
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License Number State | NY
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