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General NPI Number Information
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NPI Number | 1649315771
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Entity Type | Organization
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Legal Business Name | 112 GVR MEDICAL, PC
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6960 108TH ST SUITE 108
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City | FOREST HILLS
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State | NY
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Zip | 11375-4323
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Country | US
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Telephone | 718-263-0200
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Fax | 718-263-0205
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Provider Business Mailing Address
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Address Line | 6960 108TH ST SUITE 108
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City | FOREST HILLS
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State | NY
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Zip | 11375-4323
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Country | US
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Telephone | 718-263-0200
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Fax | 718-263-0205
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Authorized Official
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Title or Position | OWNER
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Name | IDA TETRO
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Credential | MD
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Telephone | 718-263-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 220405
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License Number State | NY
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