Provider Demographics
NPI:1255695078
Name:NORTH SHORE MEDICAL DIAGNOSTIC PC
Entity Type:Organization
Organization Name:NORTH SHORE MEDICAL DIAGNOSTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IFFAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SADIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-462-9015
Mailing Address - Street 1:1024 PENINSULA BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3044 CONEY ISLAND AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5660
Practice Address - Country:US
Practice Address - Phone:718-934-1400
Practice Address - Fax:718-934-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230830261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology