Provider Demographics
NPI:1407925977
Name:DEVICKA PERSAUD MEDICAL PC
Entity Type:Organization
Organization Name:DEVICKA PERSAUD MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEVICKA
Authorized Official - Middle Name:DEVI
Authorized Official - Last Name:PERSAUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-641-3389
Mailing Address - Street 1:11512 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-1902
Mailing Address - Country:US
Mailing Address - Phone:718-641-3389
Mailing Address - Fax:718-879-6444
Practice Address - Street 1:11512 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1902
Practice Address - Country:US
Practice Address - Phone:718-641-3389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty