Provider Demographics
NPI:1447535323
Name:ABBYDEK FAMILY MEDICAL PRACTICE PC
Entity type:Organization
Organization Name:ABBYDEK FAMILY MEDICAL PRACTICE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:OLUSEGUN
Authorized Official - Last Name:FASHAKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-591-1600
Mailing Address - Street 1:7935 153RD ST
Mailing Address - Street 2:APT 1
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3937
Mailing Address - Country:US
Mailing Address - Phone:718-591-1600
Mailing Address - Fax:718-591-0265
Practice Address - Street 1:7935 153RD ST
Practice Address - Street 2:APT 1
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3937
Practice Address - Country:US
Practice Address - Phone:718-591-1600
Practice Address - Fax:718-591-0265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202847261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01652235Medicaid
NY202847OtherLICENSE
NYG26238Medicare UPIN