Provider Demographics
NPI:1275588022
Name:KIRTANE, YASHODHARA
Entity Type:Individual
Prefix:
First Name:YASHODHARA
Middle Name:
Last Name:KIRTANE
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 1:114-12 BEACH CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1514
Mailing Address - Country:US
Mailing Address - Phone:718-318-6021
Mailing Address - Fax:718-318-4802
Practice Address - Street 1:114-12 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-1514
Practice Address - Country:US
Practice Address - Phone:718-318-6021
Practice Address - Fax:718-318-4802
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154995207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2099733OtherGHI
NY271AU2OtherBC/BS
NY2099733OtherGHI
NYA62739Medicare UPIN