Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2026-05-07
- Last updated
- 2026-05-07
Specialties
Licenses
- License NY
- 3030333
Location
- Practice location
- 49 E GLENWILD DRIVE
- City
- SMALLWOOD NY
- Postal code
- 12778
- Phone
- 845-798-5968
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.