Provider Demographics
NPI:1689397747
Name:REJA, MOUSUMI
Entity Type:Individual
Prefix:
First Name:MOUSUMI
Middle Name:
Last Name:REJA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9513 120TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-1307
Mailing Address - Country:US
Mailing Address - Phone:347-752-0053
Mailing Address - Fax:
Practice Address - Street 1:11220 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1814
Practice Address - Country:US
Practice Address - Phone:646-498-4544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1104310440207R00000X
NY029234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty