1689791352 NPI number — LAWRENCE EDWARD DRESDALE PH.D.

Table of content: (NPI 1215750658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689791352 NPI number — LAWRENCE EDWARD DRESDALE PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRESDALE
Provider First Name:
LAWRENCE
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689791352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
721 BROADWAY # 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12401-3449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-331-2007
Provider Business Mailing Address Fax Number:
845-339-2382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 GREEN ST.
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-339-2352
Provider Business Practice Location Address Fax Number:
845-339-2382
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  007948 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00977344 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 986103 . This is a "MVP HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 135390 . This is a "VALUEOPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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