Provider Demographics
NPI:1457432304
Name:MOLLICK ETRA ETRA & COHEN
Entity Type:Organization
Organization Name:MOLLICK ETRA ETRA & COHEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:ETRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-487-6200
Mailing Address - Street 1:560 NORTHERN BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5100
Mailing Address - Country:US
Mailing Address - Phone:516-487-6200
Mailing Address - Fax:516-487-6329
Practice Address - Street 1:560 NORTHERN BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5100
Practice Address - Country:US
Practice Address - Phone:516-487-6200
Practice Address - Fax:516-487-6329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215924207KA0200X
NY217820207ND0101X
NY128003207Y00000X
NY127393207Y00000X
NY125573207Y00000X
NY207896207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWES172Medicare ID - Type UnspecifiedGROUP PROVIDER ID