Provider Demographics
NPI:1760483077
Name:NATH, SUNIL (MD)
Entity Type:Individual
Prefix:
First Name:SUNIL
Middle Name:
Last Name:NATH
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 1:55 14 MAIN ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:718-359-3131
Mailing Address - Fax:
Practice Address - Street 1:55 14 MAIN ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-359-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2008-01-30
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
NY141736207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00814113Medicaid
NYP00069845OtherMC RR
05841Medicare ID - Type Unspecified
B58721Medicare UPIN