Provider Demographics
NPI:1962655738
Name:NEW YORK DERMATOLOGY & MOHS SURGERY GROUP, PLLC
Entity Type:Organization
Organization Name:NEW YORK DERMATOLOGY & MOHS SURGERY GROUP, PLLC
Other - Org Name:NEW YORK DERMATOLOGY & SKIN CANCER CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:APRIL
Authorized Official - Last Name:SERURE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-543-4888
Mailing Address - Street 1:353 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4200
Mailing Address - Country:US
Mailing Address - Phone:631-543-4888
Mailing Address - Fax:631-543-3549
Practice Address - Street 1:225 W MONTAUK HWY
Practice Address - Street 2:SUITE 3
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-3531
Practice Address - Country:US
Practice Address - Phone:631-728-7288
Practice Address - Fax:631-728-4010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205536207N00000X, 207NS0135X
NY222859207N00000X, 207ND0101X, 207NS0135X
NY215146207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY222859OtherNY STATE LICENSE
NY205536OtherNY STATE LICENSE
NY222859OtherNY STATE LICENSE
NY205536OtherNY STATE LICENSE
NYI51657Medicare UPIN
NYBA9331985OtherDEA #