Provider Demographics
NPI:1689972317
Name:CRYSTAL MEDICAL CARE,P.C.
Entity Type:Organization
Organization Name:CRYSTAL MEDICAL CARE,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VISHWANATH
Authorized Official - Middle Name:VALAGEREHALLY
Authorized Official - Last Name:PUTTASWAMYGOWDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:718-803-6300
Mailing Address - Street 1:6914 41ST AVE
Mailing Address - Street 2:STE C1
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4028
Mailing Address - Country:US
Mailing Address - Phone:718-803-6300
Mailing Address - Fax:718-803-2434
Practice Address - Street 1:6914 41ST AVE
Practice Address - Street 2:STE C1
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4028
Practice Address - Country:US
Practice Address - Phone:718-803-6300
Practice Address - Fax:718-803-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03260455Medicaid