Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | 161323-1 | NY |
N | 207YP0228X | Pediatric Otolaryngology | 161323-1 | NY |
NPI | 1568463909 |
---|---|
Provider Name | Idel I Moisa |
First Address | Glen Cove, NY 11542-2548 |
Second Address | Glen Cove, NY 11542-2548 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2005 |
Last Update Date | 03/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A61864 | (02) |