Healthcare Provider Details

I. General information

NPI: 1659348423
Provider Name (Legal Business Name): VINOD BOPAIAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SEAVIEW AVENUE
STATEN ISLAND NY
10305
US

IV. Provider business mailing address

400 SEAVIEW AVENUE
STATEN ISLAND NY
10305
US

V. Phone/Fax

Practice location:
  • Phone: 718-351-0199
  • Fax: 718-667-4225
Mailing address:
  • Phone: 718-351-0199
  • Fax: 718-667-4225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number135378
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: