Provider Demographics
NPI:1356071526
Name:FOUR CORNERS MEDICAL PC
Entity Type:Organization
Organization Name:FOUR CORNERS MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN-YVES
Authorized Official - Middle Name:
Authorized Official - Last Name:DASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-415-7347
Mailing Address - Street 1:11622 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1017
Mailing Address - Country:US
Mailing Address - Phone:347-415-7347
Mailing Address - Fax:347-312-7197
Practice Address - Street 1:11622 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1017
Practice Address - Country:US
Practice Address - Phone:347-415-7347
Practice Address - Fax:347-312-7197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-12
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty