Healthcare Provider Details

I. General information

NPI: 1073574240
Provider Name (Legal Business Name): DEBA BANERJI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4771 HYLAN BLVD
STATEN ISLAND NY
10312-6315
US

IV. Provider business mailing address

2791 RICHMOND AVE 2ND FLOOR
STATEN ISLAND NY
10314-5859
US

V. Phone/Fax

Practice location:
  • Phone: 718-948-8200
  • Fax: 718-948-8433
Mailing address:
  • Phone: 718-816-6440
  • Fax: 718-948-8433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number192748
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: