Healthcare Provider Details

I. General information

NPI: 1942640644
Provider Name (Legal Business Name): AINIE SOETANTO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
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: 718-920-2625
  • Fax:
Mailing address:
  • Phone: 718-920-2625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number289406
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number26938410
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number289406
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: