MEDICARE: DEVICKA PERSAUD MEDICAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1407925977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVICKA PERSAUD MEDICAL PC

Provider Business Mailing Address
First Line	:	11512 LIBERTY AVE
Second Line	:
City	:	SOUTH RICHMOND HILL
State	:	NY
Zip	:	11419-1902
Country	:	US
Telephone Number	:	718-641-3389
Fax Number	:	718-879-6444

Provider Business Practice Location Address
First Line	:	11512 LIBERTY AVE
Second Line	:
City	:	SOUTH RICHMOND HILL
State	:	NY
Zip	:	11419-1902
Country	:	US
Telephone Number	:	718-641-3389
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEVICKA DEVI PERSAUD
Credential	:	M.D
Telephone Number	:	718-641-3389

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	12/03/2012

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