Healthcare Provider Details

I. General information

NPI: 1235027905
Provider Name (Legal Business Name): PRASHANTA RAJ PANTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4499 MANHATTAN COLLEGE PKWY
BRONX NY
10471-3919
US

IV. Provider business mailing address

286 S MAIN ST
NEW CITY NY
10956-3327
US

V. Phone/Fax

Practice location:
  • Phone: 859-559-6999
  • Fax:
Mailing address:
  • Phone: 845-362-8400
  • Fax: 845-362-8474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberP131511
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: