Healthcare Provider Details

I. General information

NPI: 1689201626
Provider Name (Legal Business Name): RADHIKA GHODASARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 BROADWAY
ELMHURST NY
11373-1329
US

IV. Provider business mailing address

7901 BROADWAY
ELMHURST NY
11373-1329
US

V. Phone/Fax

Practice location:
  • Phone: 718-334-3054
  • Fax:
Mailing address:
  • Phone: 718-334-3054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number323627-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9478
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: