Provider Demographics
NPI:1043597842
Name:PRESTIGE PEDIATRIC CARE P.C.
Entity Type:Organization
Organization Name:PRESTIGE PEDIATRIC CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-445-5437
Mailing Address - Street 1:14 SARINA DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14037 CHERRY AVE
Practice Address - Street 2:APT 1A
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-7818
Practice Address - Country:US
Practice Address - Phone:718-445-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244317208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty