Provider Demographics
NPI:1861453698
Name:CHOUDHURY, SOURAB (DO)
Entity Type:Individual
Prefix:
First Name:SOURAB
Middle Name:
Last Name:CHOUDHURY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 ATLANTIC AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-6720
Mailing Address - Country:US
Mailing Address - Phone:718-797-5504
Mailing Address - Fax:
Practice Address - Street 1:161 ATLANTIC AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6720
Practice Address - Country:US
Practice Address - Phone:718-797-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226018207N00000X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02358652Medicaid
H77118Medicare UPIN
NY02358652Medicaid