Healthcare Provider Details

I. General information

NPI: 1376567925
Provider Name (Legal Business Name): DEEPAK S. MAHAJAN PHYSICIAN P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 12/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8675 MIDLAND PKWY SUITE 2
JAMAICA NY
11432-3058
US

IV. Provider business mailing address

38 LAKE DR
NEW HYDE PARK NY
11040-1123
US

V. Phone/Fax

Practice location:
  • Phone: 718-523-2177
  • Fax: 718-523-2133
Mailing address:
  • Phone: 516-627-4577
  • Fax: 718-523-2133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number238466
License Number StateNY

VIII. Authorized Official

Name: DR. SUCHETA D MAHAJAN
Title or Position: ATTENDING
Credential: M.D.
Phone: 516-627-4577