Healthcare Provider Details

I. General information

NPI: 1932354818
Provider Name (Legal Business Name): KETAN DHRUVKUMAR VORA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 10/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 BRADLEY AVE
STATEN ISLAND NY
10314-4403
US

IV. Provider business mailing address

24 BRADLEY AVE
STATEN ISLAND NY
10314-4403
US

V. Phone/Fax

Practice location:
  • Phone: 347-878-2225
  • Fax: 516-717-3556
Mailing address:
  • Phone: 347-878-2225
  • Fax: 516-717-3556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number243182
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number243182
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: