Provider Demographics
NPI:1083784607
Name:SIU, ANITA C
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:C
Last Name:SIU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 GAYLORD DRIVE NORTH
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6712
Mailing Address - Country:US
Mailing Address - Phone:718-951-2519
Mailing Address - Fax:718-258-0654
Practice Address - Street 1:3024 AVENUE I
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3033
Practice Address - Country:US
Practice Address - Phone:718-951-2519
Practice Address - Fax:718-258-0654
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117888208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
B18321Medicare UPIN
683811Medicare ID - Type Unspecified