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General NPI Number Information
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NPI Number | 1861738460
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Entity Type | Organization
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Legal Business Name | RADIANT SKIN DERMATOLOGY AND LASER,PLLC
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Dates
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Enumeration Date | 12/31/2012
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Last Update Date | 03/04/2024
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Provider Practice Location Address
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Address Line | 207 W 115TH ST LOWR LEVEL
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City | NEW YORK
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State | NY
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Zip | 10026-2965
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Country | US
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Telephone | 212-229-0007
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Fax | 347-274-8349
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Provider Business Mailing Address
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Address Line | 234 CENTRAL PARK W
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City | NEW YORK
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State | NY
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Zip | 10024-6003
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Country | US
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Telephone | 212-229-0007
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Fax | 212-202-6350
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Authorized Official
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Title or Position | OWNER
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Name | ADEBOLA OLUFUNMI DELE-MICHAEL
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Credential | MD
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Telephone | 212-229-0007
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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 | 256265
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License Number State | NY
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