Healthcare Provider Details

I. General information

NPI: 1710690821
Provider Name (Legal Business Name): SARA SAMEH ISRAEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 MAIN ST
FLUSHING NY
11355-5045
US

IV. Provider business mailing address

6509 68TH AVE
RIDGEWOOD NY
11385-4652
US

V. Phone/Fax

Practice location:
  • Phone: 718-670-2000
  • Fax:
Mailing address:
  • Phone: 646-595-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number029441
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: