MEDICARE: PAUL PROMADHATTVEDI M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program	MT212736	PA
2	208D00000X	General Practice Physician	301528	NY

General Provider Information

NPI Number	:	1992231294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL PROMADHATTVEDI M.D.

Provider Business Mailing Address
First Line	:	255 FORT WASHINGTON AVE
Second Line	:	APT 41
City	:	NEW YORK
State	:	NY
Zip	:	10032-1229
Country	:	US
Telephone Number	:	917-328-3232
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 FORT WASHINGTON AVE APT 41
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10032-1252
Country	:	US
Telephone Number	:	917-328-3232
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2017
Last Update Date	:	12/15/2019

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