Provider Demographics
NPI:1578704235
Name:SMALL, TANIA (MD)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10439 198TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-1215
Mailing Address - Country:US
Mailing Address - Phone:718-740-7527
Mailing Address - Fax:
Practice Address - Street 1:630 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3725
Practice Address - Country:US
Practice Address - Phone:212-305-8504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251753208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics