Healthcare Provider Details

I. General information

NPI: 1326627183
Provider Name (Legal Business Name): KEVIN P. MUTHU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 BROADWAY
ELMHURST NY
11373-1329
US

IV. Provider business mailing address

157 E 86TH ST # 468
NEW YORK NY
10028-2175
US

V. Phone/Fax

Practice location:
  • Phone: 718-334-4000
  • Fax:
Mailing address:
  • Phone: 718-334-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number343480
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: