Healthcare Provider Details

I. General information

NPI: 1417351487
Provider Name (Legal Business Name): MAYA FAKHOURY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 AMSTERDAM AVE
NEW YORK NY
10025-1716
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL # 1118
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 212-523-4000
  • Fax:
Mailing address:
  • Phone: 212-241-0896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MA10792400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number305042
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: