Provider Demographics
NPI:1700414737
Name:GULFAM, NIDA
Entity Type:Individual
Prefix:MRS
First Name:NIDA
Middle Name:
Last Name:GULFAM
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 1:100 NICOLLS ROAD DEPARTMENT OF PSYCHIATRY
Mailing Address - Street 2:HEALTH SCIENCE TOWER, LEVEL T-10, ROOM 020
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11796-8101
Mailing Address - Country:US
Mailing Address - Phone:631-444-2990
Mailing Address - Fax:
Practice Address - Street 1:100 NICOLLS ROAD DEPARTMENT OF PSYCHIATRY
Practice Address - Street 2:HEALTH SCIENCE TOWER, LEVEL T-10, ROOM 020
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11796-8101
Practice Address - Country:US
Practice Address - Phone:631-444-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program