Healthcare Provider Details

I. General information

NPI: 1346336559
Provider Name (Legal Business Name): PRAKASH SURYA KANCHERLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2358 CROTONA AVE 1ST FLOOR
BRONX NY
10458-8571
US

IV. Provider business mailing address

2358 CROTONA AVE 1ST FLOOR
BRONX NY
10458-8571
US

V. Phone/Fax

Practice location:
  • Phone: 718-733-2600
  • Fax: 718-562-2281
Mailing address:
  • Phone: 718-733-2600
  • Fax: 718-562-2281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number130852
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: