Provider Demographics
NPI:1720158660
Name:DOLSON AVENUE MEDICAL
Entity type:Organization
Organization Name:DOLSON AVENUE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-342-0746
Mailing Address - Street 1:PO BOX 884
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-0884
Mailing Address - Country:US
Mailing Address - Phone:845-342-0746
Mailing Address - Fax:845-342-1397
Practice Address - Street 1:54 DOLSON AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940
Practice Address - Country:US
Practice Address - Phone:845-342-0746
Practice Address - Fax:845-342-1397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
NY174296208100000X, 2081P2900X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W85391Medicare UPIN
6464330001Medicare NSC