Provider Demographics
NPI:1346440823
Name:PESALA, NAVEEN KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:NAVEEN
Middle Name:KUMAR
Last Name:PESALA
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 1:51 SAINT NICHOLAS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-3467
Mailing Address - Country:US
Mailing Address - Phone:646-360-3784
Mailing Address - Fax:917-398-1563
Practice Address - Street 1:51 SAINT NICHOLAS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-3467
Practice Address - Country:US
Practice Address - Phone:646-360-3784
Practice Address - Fax:917-398-1563
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03333135Medicaid
NYA300072571Medicare PIN