Provider Demographics
NPI:1588214357
Name:ADVANCED DERMATOLOGY OF NEW YORK PC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY OF NEW YORK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAULELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-262-2500
Mailing Address - Street 1:200 CENTRAL PARK S APT 107
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1449
Mailing Address - Country:US
Mailing Address - Phone:212-262-2500
Mailing Address - Fax:212-765-3210
Practice Address - Street 1:1-3 WEST 125TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027
Practice Address - Country:US
Practice Address - Phone:212-246-6800
Practice Address - Fax:212-765-3210
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DERMATOLOGY OF NEW YORK PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty