Provider Demographics
NPI:1477971943
Name:ALEISSA, SAUD
Entity Type:Individual
Prefix:
First Name:SAUD
Middle Name:
Last Name:ALEISSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 EAST 73RD STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022
Mailing Address - Country:US
Mailing Address - Phone:703-896-8004
Mailing Address - Fax:
Practice Address - Street 1:530 EAST 73RD STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:703-896-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263596207N00000X
390200000X
NY293878207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program