Provider Demographics
NPI:1952505331
Name:WOODSIDE MEDICAL DIAGNOSTIC, PC.
Entity Type:Organization
Organization Name:WOODSIDE MEDICAL DIAGNOSTIC, PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:ENDORA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DRAGOMIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-545-5947
Mailing Address - Street 1:3120 54TH ST
Mailing Address - Street 2:SUITE L2
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-1530
Mailing Address - Country:US
Mailing Address - Phone:718-476-5859
Mailing Address - Fax:718-476-9859
Practice Address - Street 1:3120 54TH ST
Practice Address - Street 2:SUITE L2
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-1530
Practice Address - Country:US
Practice Address - Phone:718-476-5859
Practice Address - Fax:718-476-9859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01130987Medicaid
NYE57629Medicare UPIN
NY07607Medicare ID - Type Unspecified