Provider Demographics
NPI:1750509311
Name:NATH, PREM (MD)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:
Last Name:NATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:17 EDINBURGH RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-1704
Mailing Address - Country:US
Mailing Address - Phone:845-782-8242
Mailing Address - Fax:845-358-9602
Practice Address - Street 1:9 INGALLS ST
Practice Address - Street 2:SUITE 25
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-2318
Practice Address - Country:US
Practice Address - Phone:845-641-6778
Practice Address - Fax:845-358-9602
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY133218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC08975Medicare UPIN