Healthcare Provider Details

I. General information

NPI: 1083077341
Provider Name (Legal Business Name): ELISE KOCHOUMIAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2016
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 1ST ST
MINEOLA NY
11501-3957
US

IV. Provider business mailing address

100 E 77TH ST
NEW YORK NY
10075-1850
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-8963
  • Fax: 516-663-8964
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number299579
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: