Provider Demographics
NPI:1558492314
Name:UROLOGY DYNAMIC, PC
Entity Type:Organization
Organization Name:UROLOGY DYNAMIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AYAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RASOOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-268-7262
Mailing Address - Street 1:7603 113TH ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6530
Mailing Address - Country:US
Mailing Address - Phone:718-204-0414
Mailing Address - Fax:718-204-7470
Practice Address - Street 1:7603 113TH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6530
Practice Address - Country:US
Practice Address - Phone:718-204-0414
Practice Address - Fax:718-204-7470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152821208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00763731Medicaid
NYB88593Medicare UPIN
NY00763731Medicaid