Provider Demographics
NPI:1891704011
Name:AMIN, ANJUMON A (MD)
Entity Type:Individual
Prefix:
First Name:ANJUMON
Middle Name:A
Last Name:AMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738
Mailing Address - Country:US
Mailing Address - Phone:631-736-8589
Mailing Address - Fax:
Practice Address - Street 1:550 MONTAUK HIGHWAY
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967
Practice Address - Country:US
Practice Address - Phone:631-852-1001
Practice Address - Fax:631-852-1122
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196797208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01770167Medicaid
370008547OtherRR
AA078J8710Medicare ID - Type Unspecified
NY01770167Medicaid