Healthcare Provider Details

I. General information

NPI: 1063072106
Provider Name (Legal Business Name): RISHABH DEV PHUKAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF CHILD AND ADOLESCENT PSYCHIATRY
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD DIVISION OF CHILD AND ADOLESCENT PSYCHIATRY
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-7131
  • Fax:
Mailing address:
  • Phone: 215-590-7131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD482097
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: