Healthcare Provider Details

I. General information

NPI: 1346321874
Provider Name (Legal Business Name): ALICEKUTTY NELPURA JOHN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 CROOKED HILL RD
W BRENTWOOD NY
11717-1043
US

IV. Provider business mailing address

26 KRISTI DR
JERICHO NY
11753-1309
US

V. Phone/Fax

Practice location:
  • Phone: 631-761-3127
  • Fax:
Mailing address:
  • Phone: 516-822-0241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number233968
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: