1699913145 NPI number — ST. DEMIAN MEDICAL PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699913145 NPI number — ST. DEMIAN MEDICAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. DEMIAN MEDICAL PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1699913145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
174 BAY 29TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-758-4520
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 IVY WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-758-4520
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SHAROBEEM
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
718-758-4520

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  183484 , 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)





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