Provider Demographics
NPI:1538305248
Name:MUKHERJEE, KOUSTAV (MD)
Entity Type:Individual
Prefix:DR
First Name:KOUSTAV
Middle Name:
Last Name:MUKHERJEE
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 1:60 W 66TH ST
Mailing Address - Street 2:#9I
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 SELWYN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7626
Practice Address - Country:US
Practice Address - Phone:718-960-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY252331207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program