=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649378704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETH SHAPIRO BROMBERG MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 05/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 334 UNDERHILL AVENUE BUILDING #4 SUITE B
-----------------------------------------------------
City | YORKTOWN HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-962-5054
-----------------------------------------------------
Fax | 914-962-8115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 334 UNDERHILL AVENUE BUILDING #4 SUITE B
-----------------------------------------------------
City | YORKTOWN HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-962-5054
-----------------------------------------------------
Fax | 914-962-8115
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 164082
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------