Healthcare Provider Details

I. General information

NPI: 1790865764
Provider Name (Legal Business Name): RACHID ELKOUSTAF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/08/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MARYS AVE SUITE 3
KINGSTON NY
12401-5852
US

IV. Provider business mailing address

4 ATRIUM DR STE 100, ATTN: TAMMY M. TAFT
ALBANY NY
12205-1522
US

V. Phone/Fax

Practice location:
  • Phone: 845-339-3663
  • Fax: 845-339-3629
Mailing address:
  • Phone: 518-435-2740
  • Fax: 518-458-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number102692
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number244744
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: