Healthcare Provider Details

I. General information

NPI: 1225208564
Provider Name (Legal Business Name): DIGESTIVE DISEASES & NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 11/05/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 61 HILLSIDE AVE STE 402
JAMAICA ESTATES NY
11432-5796
US

IV. Provider business mailing address

175 61 HILLSIDE AVE STE 402
JAMAICA ESTATES NY
11432-5796
US

V. Phone/Fax

Practice location:
  • Phone: 718-291-0488
  • Fax: 718-291-0888
Mailing address:
  • Phone: 516-330-6615
  • Fax: 718-291-0888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number189770
License Number StateNY

VIII. Authorized Official

Name: ROM M GUPTA
Title or Position: OWNER
Credential: MD
Phone: 516-330-6615