Healthcare Provider Details

I. General information

NPI: 1073449864
Provider Name (Legal Business Name): RAIYAN ISHRAQUE DEEPON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 BEACH 48TH ST
FAR ROCKAWAY NY
11691-1120
US

IV. Provider business mailing address

1583 E 66TH ST FL 1
BROOKLYN NY
11234-6005
US

V. Phone/Fax

Practice location:
  • Phone: 516-862-1600
  • Fax:
Mailing address:
  • Phone: 516-505-4560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP142691
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: