Healthcare Provider Details

I. General information

NPI: 1487685129
Provider Name (Legal Business Name): SEIN THAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 PORT RICHMOND AVE
STATEN ISLAND NY
10302-1714
US

IV. Provider business mailing address

58 ANDES PL
STATEN ISLAND NY
10314-5525
US

V. Phone/Fax

Practice location:
  • Phone: 718-924-2254
  • Fax: 718-442-0189
Mailing address:
  • Phone: 917-518-0921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number219042
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: