Provider Demographics
NPI:1922306901
Name:TDL MEDICAL,PC
Entity Type:Organization
Organization Name:TDL MEDICAL,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:THEODORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-960-2544
Mailing Address - Street 1:2546 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3516
Mailing Address - Country:US
Mailing Address - Phone:718-368-0300
Mailing Address - Fax:718-368-0301
Practice Address - Street 1:2546 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3516
Practice Address - Country:US
Practice Address - Phone:718-368-0300
Practice Address - Fax:718-368-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF20112Medicare UPIN