Healthcare Provider Details

I. General information

NPI: 1760506836
Provider Name (Legal Business Name): SAM TRAISAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MAIN ST
ROOSEVELT ISLAND NY
10044-0052
US

IV. Provider business mailing address

1 MAIN ST
ROOSEVELT ISLAND NY
10044-0052
US

V. Phone/Fax

Practice location:
  • Phone: 212-318-4242
  • Fax:
Mailing address:
  • Phone: 212-318-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number16335801
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: