Provider Demographics
NPI:1659782589
Name:INNOVATIVE UROLOGY PRACTICE OF NEW YORK, PLLC
Entity Type:Organization
Organization Name:INNOVATIVE UROLOGY PRACTICE OF NEW YORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:I
Authorized Official - Last Name:FISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-455-1170
Mailing Address - Street 1:92-29 QUEENS BLVD.
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1072
Mailing Address - Country:US
Mailing Address - Phone:718-606-6912
Mailing Address - Fax:718-606-6914
Practice Address - Street 1:92-29 QUEENS BLVD.
Practice Address - Street 2:SUITE 2B
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1072
Practice Address - Country:US
Practice Address - Phone:718-606-6912
Practice Address - Fax:718-606-6914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248604208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty