Provider Demographics
NPI:1558714584
Name:MOONLIGHT PEDIATRICS OF NYC, P.C.
Entity Type:Organization
Organization Name:MOONLIGHT PEDIATRICS OF NYC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-362-8400
Mailing Address - Street 1:26 FIREMENS MEMORIAL DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 W 25TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7243
Practice Address - Country:US
Practice Address - Phone:800-750-8616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty