Healthcare Provider Details

I. General information

NPI: 1396365672
Provider Name (Legal Business Name): SAMRATH NENWANI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 ROE AVE
ELMIRA NY
14905-1629
US

IV. Provider business mailing address

600 IVY ST STE 206
ELMIRA NY
14905-1627
US

V. Phone/Fax

Practice location:
  • Phone: 607-737-7012
  • Fax: 607-733-5594
Mailing address:
  • Phone: 607-271-2050
  • Fax: 607-271-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number313142
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: