Provider Demographics
NPI:1770243529
Name:25-15 CRESCENT STREET MEDICAL PC
Entity Type:Organization
Organization Name:25-15 CRESCENT STREET MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GOHAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-897-5331
Mailing Address - Street 1:10818 63RD RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1352
Mailing Address - Country:US
Mailing Address - Phone:718-897-5331
Mailing Address - Fax:
Practice Address - Street 1:10818 63RD RD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1352
Practice Address - Country:US
Practice Address - Phone:718-897-5331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty