Healthcare Provider Details

I. General information

NPI: 1861453698
Provider Name (Legal Business Name): SOURAB CHOUDHURY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 ATLANTIC AVE SUITE 202
BROOKLYN NY
11201-6720
US

IV. Provider business mailing address

161 ATLANTIC AVE SUITE 202
BROOKLYN NY
11201-6720
US

V. Phone/Fax

Practice location:
  • Phone: 718-797-5504
  • Fax:
Mailing address:
  • Phone: 718-797-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number226018
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number226018
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: