MEDICARE: CONEY ISLAND MEDICAL DIAGNOSTIC SERVICES P C

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	207ZP0101X	Anatomic Pathology Physician

General Provider Information

NPI Number	:	1902436728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONEY ISLAND MEDICAL DIAGNOSTIC SERVICES P C

Provider Business Mailing Address
First Line	:	PO BOX 86
Second Line	:
City	:	JERICHO
State	:	NY
Zip	:	11753-0086
Country	:	US
Telephone Number	:	516-567-5410
Fax Number	:

Provider Business Practice Location Address
First Line	:	1704 MERMAID AVE STE 6
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224-2622
Country	:	US
Telephone Number	:	516-567-5410
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KONSTANTIN VAIZMAN
Credential	:	MD
Telephone Number	:	347-446-6839

Provider Enumeration Date	:	01/21/2020
Last Update Date	:	01/21/2020

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