Provider Demographics
NPI:1487674396
Name:NEDUNCHEZIAN, DEEPTHA (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPTHA
Middle Name:
Last Name:NEDUNCHEZIAN
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 1:514 49TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-2010
Mailing Address - Country:US
Mailing Address - Phone:718-431-2600
Mailing Address - Fax:718-436-7810
Practice Address - Street 1:514 49TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2010
Practice Address - Country:US
Practice Address - Phone:718-431-2600
Practice Address - Fax:718-436-7810
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140066207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01473972Medicaid
NY76A111Medicare ID - Type Unspecified
NY01473972Medicaid