Healthcare Provider Details

I. General information

NPI: 1962296590
Provider Name (Legal Business Name): ANJALI PRAKASH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 VARICK ST RM 900
NEW YORK NY
10014-4893
US

IV. Provider business mailing address

235 GRAND ST APT 4305
JERSEY CITY NJ
07302-4794
US

V. Phone/Fax

Practice location:
  • Phone: 212-620-0340
  • Fax:
Mailing address:
  • Phone: 610-500-6226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number335996
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: