Provider Demographics
NPI:1164533287
Name:TOM, WINSTON C (MD)
Entity Type:Individual
Prefix:DR
First Name:WINSTON
Middle Name:C
Last Name:TOM
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 1:254 CANAL ST RM 3005
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-3501
Mailing Address - Country:US
Mailing Address - Phone:212-941-8273
Mailing Address - Fax:212-226-5029
Practice Address - Street 1:254 CANAL ST RM 3005
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3501
Practice Address - Country:US
Practice Address - Phone:212-941-8273
Practice Address - Fax:212-226-5029
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159365174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01081323Medicaid
NY22E701Medicare ID - Type Unspecified
NY01081323Medicaid