Healthcare Provider Details

I. General information

NPI: 1750509311
Provider Name (Legal Business Name): PREM NATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 INGALLS ST SUITE 25
NYACK NY
10960-2318
US

IV. Provider business mailing address

17 EDINBURGH RD
MIDDLETOWN NY
10941-1704
US

V. Phone/Fax

Practice location:
  • Phone: 845-641-6778
  • Fax: 845-358-9602
Mailing address:
  • Phone: 845-782-8242
  • Fax: 845-358-9602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number133218
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: