Healthcare Provider Details

I. General information

NPI: 1790747343
Provider Name (Legal Business Name): THRESIAMMA GEORGE THANJAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 GRAND CONCOURSE SUITE 1 J
BRONX NY
10458-2611
US

IV. Provider business mailing address

2859 CRESTON AVE SUITE 1 J
BRONX NY
10468-1806
US

V. Phone/Fax

Practice location:
  • Phone: 718-367-0211
  • Fax: 718-367-0211
Mailing address:
  • Phone: 718-367-0211
  • Fax: 718-367-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number135671
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: