| | Physician Last Name: | Fowler Street Medical |
| | Physician First Name: | P.C. |
| | Physician Middle Name: | |
| | Address: | c/o Vlad Meisher
29 Victoria Place East
Fort Lee, New Jersey 07024 |
| | License Number: | 186086 |
| | License Type: | |
| | Year of Birth: |
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| | Effective Date: | 12/19/2006 |
| | Action Description for DOH Webpage: | Revocation of Certificate of Incorporation. |
| | Misconduct Description for DOH Webpage: | The Corporation was rendered in violation of New York State Business Corporation Law Section 1503(a) and (b) and 1504(a) by virtue of the surrender of the sole shareholder's medical license. |
| | License Limitations or Conditions for DOH Webpage: | |
| | Board Order: |
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