Provider Demographics
NPI:1073574240
Name:BANERJI, DEBA (MD)
Entity Type:Individual
Prefix:
First Name:DEBA
Middle Name:
Last Name:BANERJI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 RICHMOND AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5859
Mailing Address - Country:US
Mailing Address - Phone:718-816-6440
Mailing Address - Fax:718-948-8433
Practice Address - Street 1:4771 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-6315
Practice Address - Country:US
Practice Address - Phone:718-948-8200
Practice Address - Fax:718-948-8433
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192748207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01724285Medicaid
NY01724285Medicaid
NY56N28GW791Medicare PIN