Provider Demographics
NPI:1558691659
Name:CAPITAL DISTRICT MEDICAL & WELLNESS PC
Entity Type:Organization
Organization Name:CAPITAL DISTRICT MEDICAL & WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:STAFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-869-4300
Mailing Address - Street 1:3 STANDISH PL
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-2914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 WEMBLEY CT
Practice Address - Street 2:SUITE 101
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-3891
Practice Address - Country:US
Practice Address - Phone:518-869-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty