Provider Demographics
NPI:1891094322
Name:MARIWALLA DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:MARIWALLA DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAVITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIWALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-665-3376
Mailing Address - Street 1:1253 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4916
Mailing Address - Country:US
Mailing Address - Phone:631-665-3376
Mailing Address - Fax:631-969-3376
Practice Address - Street 1:1253 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4916
Practice Address - Country:US
Practice Address - Phone:631-665-3376
Practice Address - Fax:631-969-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty