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NPI Code Detail

MEDICARE: 1091 SOUTHERN BLVD DERMATOLOGY PLLC

MEDICARE: 1091 SOUTHERN BLVD DERMATOLOGY PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207N00000XDermatology Physician

General Provider Information

NPI Number : 1154004133
Entity Type Code : Organization
Provider Name (Legal Business Name) : 1091 SOUTHERN BLVD DERMATOLOGY PLLC
Provider Business Mailing Address
First Line : 4037 74TH ST
Second Line :
City : ELMHURST
State : NY
Zip : 11373-5603
Country : US
Telephone Number : 347-642-9802
Fax Number : 347-642-9852
Provider Business Practice Location Address
First Line : 1091 SOUTHERN BLVD
Second Line :
City : BRONX
State : NY
Zip : 10459-2417
Country : US
Telephone Number : 718-401-7000
Fax Number : 917-473-7878
Authorized Official
Title or Position : OFFICE MANAGER
Name : WENDY SANCHEZ
Credential :
Telephone Number : 347-642-9802
Provider Enumeration Date : 08/08/2023
Last Update Date : 08/08/2023

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