Provider Demographics
NPI:1093782492
Name:SOHO SKIN AND LASER DERMATOLOGY PC
Entity Type:Organization
Organization Name:SOHO SKIN AND LASER DERMATOLOGY PC
Other - Org Name:SOHO SKIN & LASER DERMATOLOGY, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMAHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-571-2121
Mailing Address - Street 1:347 MOUNT PLEASANT AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2749
Mailing Address - Country:US
Mailing Address - Phone:973-571-2121
Mailing Address - Fax:973-498-0569
Practice Address - Street 1:197 GRAND ST STE 3E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3859
Practice Address - Country:US
Practice Address - Phone:212-431-7600
Practice Address - Fax:212-431-7521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X
NYNY165531261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNS780Medicare UPIN
NY96F481Medicare ID - Type UnspecifiedMEDICARE INSURANCE