Provider Demographics
NPI:1205060662
Name:MANHASSET DERMATOLOGY, P.C.
Entity type:Organization
Organization Name:MANHASSET DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:WALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-365-8030
Mailing Address - Street 1:1165 NORTHERN BLVD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3048
Mailing Address - Country:US
Mailing Address - Phone:516-365-8030
Mailing Address - Fax:516-365-8058
Practice Address - Street 1:1165 NORTHERN BLVD
Practice Address - Street 2:SUITE 405
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3048
Practice Address - Country:US
Practice Address - Phone:516-365-8030
Practice Address - Fax:516-365-8058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191586174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty