Provider Demographics
NPI:1598852329
Name:DERMATOLOGY & PLASTIC SURGERY OF NORTHERN NEW YORK PC
Entity Type:Organization
Organization Name:DERMATOLOGY & PLASTIC SURGERY OF NORTHERN NEW YORK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LICZNERSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-786-1500
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-0091
Mailing Address - Country:US
Mailing Address - Phone:315-782-4207
Mailing Address - Fax:
Practice Address - Street 1:826 WASHINGTON STREET
Practice Address - Street 2:SUITE 104
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4065
Practice Address - Country:US
Practice Address - Phone:315-786-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA0167OtherGROUP NUMBER