Provider Demographics
NPI:1760802490
Name:DHALL, EDWIN
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:DHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-6922
Mailing Address - Country:US
Mailing Address - Phone:631-456-8854
Mailing Address - Fax:631-561-4245
Practice Address - Street 1:712 BROADWAY
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-6922
Practice Address - Country:US
Practice Address - Phone:631-456-8854
Practice Address - Fax:631-561-4245
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC13-26498332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY352479821OtherHMO