Healthcare Provider Details

I. General information

NPI: 1124201322
Provider Name (Legal Business Name): YUDHISTIRA PERSAUD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 FULTON AVE
BRONX NY
10456-3402
US

IV. Provider business mailing address

14833 87TH RD
BRIARWOOD NY
11435-3113
US

V. Phone/Fax

Practice location:
  • Phone: 718-590-1800
  • Fax: 718-518-5124
Mailing address:
  • Phone: 917-584-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number231667
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: