Healthcare Provider Details

I. General information

NPI: 1104357391
Provider Name (Legal Business Name): PRIYA PURUSHOTHAMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 01/21/2024
Certification Date: 01/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 E 34TH ST
NEW YORK NY
10016-4852
US

IV. Provider business mailing address

223 E 34TH ST
NEW YORK NY
10016-4852
US

V. Phone/Fax

Practice location:
  • Phone: 646-558-0800
  • Fax:
Mailing address:
  • Phone: 646-558-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number317945
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: