| | Physician Last Name: | Island Medical Professional |
| | Physician First Name: | P.C. |
| | Physician Middle Name: | |
| | Address: | 40 E. Merrick Road, Suite 106
Valley Stream, NY 11580 |
| | License Number: | 098458 |
| | License Type: | |
| | Year of Birth: |
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| | Effective Date: | 10/13/2008 |
| | Action Description for DOH Webpage: | Annulment of Certificate of Incorporation |
| | Misconduct Description for DOH Webpage: | The corporation admitted guilt to the charge of failing to comply with New York State Business Corporation Law Sections 1503 and 1514. |
| | License Limitations or Conditions for DOH Webpage: | |
| | Board Order: |
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