MEDICARE: VANGUARD DERMATOLOGY

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
1	174400000X	Specialist	234760	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619179009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANGUARD DERMATOLOGY

Provider Business Mailing Address
First Line	:	14568 3RD AVE
Second Line	:
City	:	WHITESTONE
State	:	NY
Zip	:	11357-1101
Country	:	US
Telephone Number	:	718-332-2999
Fax Number	:

Provider Business Practice Location Address
First Line	:	2119 E 15TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-4314
Country	:	US
Telephone Number	:	718-332-2999
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL SHAPIRO
Credential	:	MD
Telephone Number	:	718-332-2999

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	05/16/2008

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