Healthcare Provider Details

I. General information

NPI: 1710233952
Provider Name (Legal Business Name): PRAJITH MEPPARAMBATH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MALTESE DR
MIDDLETOWN NY
10940
US

IV. Provider business mailing address

111 MALTESE DR
MIDDLETOWN NY
10940-2141
US

V. Phone/Fax

Practice location:
  • Phone: 845-342-4774
  • Fax:
Mailing address:
  • Phone: 845-342-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number276111
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: