Provider Demographics
NPI:1982389854
Name:PEDIATRIC WELLNESS OF NORTHERN NEW YORK
Entity Type:Organization
Organization Name:PEDIATRIC WELLNESS OF NORTHERN NEW YORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MYLA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ESTEPA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-782-7330
Mailing Address - Street 1:1571 WASHINGTON ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-782-7330
Mailing Address - Fax:315-782-5773
Practice Address - Street 1:1571 WASHINGTON ST
Practice Address - Street 2:SUITE 107
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-782-7330
Practice Address - Fax:315-782-5773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-19
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty