Provider Demographics
NPI:1548267974
Name:MIN, DOROTHY L (MD)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:L
Last Name:MIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 BROADWAY
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012
Mailing Address - Country:US
Mailing Address - Phone:212-966-7600
Mailing Address - Fax:212-966-8820
Practice Address - Street 1:568 BROADWAY
Practice Address - Street 2:SUITE 304
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3225
Practice Address - Country:US
Practice Address - Phone:212-966-7600
Practice Address - Fax:212-966-8820
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231229-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02595724Medicaid
NY734D71Medicare ID - Type Unspecified
NY02595724Medicaid