Healthcare Provider Details

I. General information

NPI: 1063752897
Provider Name (Legal Business Name): VARUN PUVANESARAJAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2013
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5141 BROADWAY
NEW YORK NY
10034-1159
US

IV. Provider business mailing address

622 W 168TH ST PH 11
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-4565
  • Fax: 212-932-5067
Mailing address:
  • Phone: 212-305-5976
  • Fax: 212-305-6193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number307648
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: