MEDICARE: IAN VEBERT MALVAR DICKMAN

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	225100000X	Physical Therapist	022431-1	NY

General Provider Information

NPI Number	:	1649411711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN VEBERT MALVAR DICKMAN

Provider Business Mailing Address
First Line	:	70 PROSPECT PARK SW APT C5
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-5981
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	70 PROSPECT PARK SW APT C5
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-5981
Country	:	US
Telephone Number	:	917-862-1943
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2009
Last Update Date	:	03/18/2009

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