Provider Demographics
NPI:1457550352
Name:WAINWRIGHT DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:WAINWRIGHT DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRICIPAL PHYSICIAN - ONE MEMBER LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WAINWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-763-3000
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:CROSS RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10518-0365
Mailing Address - Country:US
Mailing Address - Phone:914-763-3000
Mailing Address - Fax:718-518-8616
Practice Address - Street 1:19 NORTH SALEM ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CROSS RIVER
Practice Address - State:NY
Practice Address - Zip Code:10518-0365
Practice Address - Country:US
Practice Address - Phone:914-763-3000
Practice Address - Fax:718-518-8616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234018207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1598737462OtherINDIVIDUAL NPI
1598737462OtherINDIVIDUAL NPI
NY3K6351Medicare PIN