Healthcare Provider Details

I. General information

NPI: 1164500518
Provider Name (Legal Business Name): PICHITRA DEJKUNCHORN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 GERARD AVE
BRONX NY
10452-8001
US

IV. Provider business mailing address

17 RADIO PL
STAMFORD CT
06906-2219
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-2875
  • Fax:
Mailing address:
  • Phone: 203-524-3917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number152581
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: