Healthcare Provider Details

I. General information

NPI: 1699147371
Provider Name (Legal Business Name): PRODIP KUMAR PAUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4433 VESTAL PKWY E
VESTAL NY
13850-3556
US

IV. Provider business mailing address

4433 VESTAL PKWY E
VESTAL NY
13850-3556
US

V. Phone/Fax

Practice location:
  • Phone: 607-240-2879
  • Fax: 607-771-2225
Mailing address:
  • Phone: 607-240-2879
  • Fax: 607-771-2225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number345819-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number345819-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: