Provider Demographics
NPI:1154871846
Name:GOLDEN AGE DERMATOLOGY PLLC
Entity type:Organization
Organization Name:GOLDEN AGE DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-734-6621
Mailing Address - Street 1:250 SKILLMAN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-1218
Mailing Address - Country:US
Mailing Address - Phone:212-734-6621
Mailing Address - Fax:516-430-5031
Practice Address - Street 1:345 E 37TH ST
Practice Address - Street 2:301
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3256
Practice Address - Country:US
Practice Address - Phone:212-734-6621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty