Provider Demographics
NPI:1720183551
Name:GOPAL, SIREEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SIREEN
Middle Name:M
Last Name:GOPAL
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 1:1250 WATERS PL STE 710
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2733
Mailing Address - Country:US
Mailing Address - Phone:718-794-0600
Mailing Address - Fax:718-684-5728
Practice Address - Street 1:1250 WATERS PL STE 710
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2733
Practice Address - Country:US
Practice Address - Phone:718-794-0600
Practice Address - Fax:718-684-5728
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY201895174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1688444Medicaid
NYG03747Medicare UPIN