Provider Demographics
NPI:1619179009
Name:VANGUARD DERMATOLOGY
Entity Type:Organization
Organization Name:VANGUARD DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-332-2999
Mailing Address - Street 1:14568 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1101
Mailing Address - Country:US
Mailing Address - Phone:718-332-2999
Mailing Address - Fax:
Practice Address - Street 1:2119 E 15TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4314
Practice Address - Country:US
Practice Address - Phone:718-332-2999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234760174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02692937Medicaid
NY02692937Medicaid
NYI08617Medicare UPIN
NYWCW671Medicare PIN
NY07396Medicare PIN