Healthcare Provider Details

I. General information

NPI: 1871546812
Provider Name (Legal Business Name): MOHINDER K GURAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 HAWKINS AVE
LAKE RONKONKOMA NY
11779-2324
US

IV. Provider business mailing address

55 WATER ST 2ND FLOOR CRED DEPT
NEW YORK NY
10041-0004
US

V. Phone/Fax

Practice location:
  • Phone: 631-737-0100
  • Fax: 631-417-1117
Mailing address:
  • Phone: 646-680-2888
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number161456
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: