Provider Demographics
NPI:1730393042
Name:PARK AVENUE DERMATOLOGY, PC
Entity type:Organization
Organization Name:PARK AVENUE DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOMINICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGRESTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-981-5040
Mailing Address - Street 1:31 TIOGA ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-4329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 TIOGA ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-4329
Practice Address - Country:US
Practice Address - Phone:718-981-5040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWLQ241Medicare ID - Type UnspecifiedLEGACY PROVIDER NUMBER