Healthcare Provider Details

I. General information

NPI: 1407316094
Provider Name (Legal Business Name): ETHAN KRELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

111 E 210TH ST
BRONX NY
10467-2401
US

V. Phone/Fax

Practice location:
  • Phone: 347-577-4410
  • Fax:
Mailing address:
  • Phone: 718-920-2060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number328063
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: