Provider Demographics
NPI:1225030133
Name:MOOKHERJEE, SULAGNA (MD)
Entity Type:Individual
Prefix:
First Name:SULAGNA
Middle Name:
Last Name:MOOKHERJEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 CEDAR RUN
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-5408
Mailing Address - Country:US
Mailing Address - Phone:518-265-7893
Mailing Address - Fax:
Practice Address - Street 1:47 NEW SCOTLAND AVE
Practice Address - Street 2:MC 44
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-5076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231562207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02569813Medicaid
NYRA2966Medicare ID - Type Unspecified
NY02569813Medicaid