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General NPI Number Information
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NPI Number | 1811232770
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Entity Type | Organization
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Legal Business Name | VITASTAT MEDICAL PLLC
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Dates
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Enumeration Date | 12/04/2012
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Last Update Date | 12/04/2012
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Provider Practice Location Address
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Address Line | 2322 BROADWAY
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City | ASTORIA
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State | NY
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Zip | 11106-4196
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Country | US
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Telephone | 917-300-8296
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Fax | 917-300-8296
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Provider Business Mailing Address
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Address Line | 8738 20TH AVE
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City | BROOKLYN
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State | NY
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Zip | 11214-4802
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Country | US
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Telephone | 917-300-8296
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Fax | 917-300-8296
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Authorized Official
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Title or Position | MANAGER
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Name | DR. KEN TRUONG
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Credential | M.D.
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Telephone | 917-300-8296
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 254736
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License Number State | NY
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