Healthcare Provider Details

I. General information

NPI: 1295097145
Provider Name (Legal Business Name): VIBHA TYAGI MS IN EDU.&SP. EDU.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 BROADHOLLOW RD SUITE #202
MELVILLE NY
11747-3676
US

IV. Provider business mailing address

58 WESTWOOD AVE
DEER PARK NY
11729-2211
US

V. Phone/Fax

Practice location:
  • Phone: 631-385-7780
  • Fax: 631-385-7795
Mailing address:
  • Phone: 631-667-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number16330
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: