Healthcare Provider Details

I. General information

NPI: 1730169210
Provider Name (Legal Business Name): GITA VATANDOUST M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

1 EDGEWATER ST 6TH FL.
STATEN ISLAND NY
10305-4900
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-6902
  • Fax: 718-226-6844
Mailing address:
  • Phone: 718-226-1008
  • Fax: 718-226-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number248813
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: