Healthcare Provider Details

I. General information

NPI: 1972065894
Provider Name (Legal Business Name): DAVID RUBEN BAMSHAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6925 170TH ST
FRESH MEADOWS NY
11365-3309
US

IV. Provider business mailing address

14744 70TH AVE APT 3
FLUSHING NY
11367-1739
US

V. Phone/Fax

Practice location:
  • Phone: 646-217-2730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number306306
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number306306
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number306306
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: