Healthcare Provider Details

I. General information

NPI: 1275400889
Provider Name (Legal Business Name): CLINS PUTHUSSERY VARGHESE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 11/02/2025
Certification Date: 11/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21273 26TH AVE
BAYSIDE NY
11360-1943
US

IV. Provider business mailing address

1308 MCCLURE AVE
ELMONT NY
11003-3311
US

V. Phone/Fax

Practice location:
  • Phone: 718-747-2019
  • Fax:
Mailing address:
  • Phone: 516-737-6833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number029972
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: