Healthcare Provider Details

I. General information

NPI: 1730234097
Provider Name (Legal Business Name): AZRA T WASTI PHYSICIAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

834 CONEY ISLAND AVE
BROOKLYN NY
11218-5310
US

IV. Provider business mailing address

834 CONEY ISLAND AVE
BROOKLYN NY
11218-5310
US

V. Phone/Fax

Practice location:
  • Phone: 718-859-5171
  • Fax: 718-469-0111
Mailing address:
  • Phone: 718-859-5171
  • Fax: 718-469-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number189994
License Number StateNY

VIII. Authorized Official

Name: DR. AZRA TABASSUM WASTI
Title or Position: OWNER
Credential: M.D.
Phone: 718-859-5171