Healthcare Provider Details

I. General information

NPI: 1154309037
Provider Name (Legal Business Name): RAJKUMAR G MARIWALLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2006
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 MONTAUK HWY SUITE #3
WEST ISLIP NY
11795-4939
US

IV. Provider business mailing address

1111 MONTAUK HWY SUITE #3-1
WEST ISLIP NY
11795-4910
US

V. Phone/Fax

Practice location:
  • Phone: 631-669-1171
  • Fax: 631-669-1912
Mailing address:
  • Phone: 631-669-1171
  • Fax: 631-669-1912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number143127
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: