Healthcare Provider Details

I. General information

NPI: 1275588022
Provider Name (Legal Business Name): YASHODHARA KIRTANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114-12 BEACH CHANNEL DR
ROCKAWAY PARK NY
11694-1514
US

IV. Provider business mailing address

114-12 BEACH CHANNEL DR
ROCKAWAY PARK NY
11694-1514
US

V. Phone/Fax

Practice location:
  • Phone: 718-318-6021
  • Fax: 718-318-4802
Mailing address:
  • Phone: 718-318-6021
  • Fax: 718-318-4802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number154995
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: