Provider Demographics
NPI:1942343959
Name:MUKHERJEE, SUSHANTA KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSHANTA
Middle Name:KUMAR
Last Name:MUKHERJEE
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 1:15 WALDO PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6750 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-5350
Practice Address - Country:US
Practice Address - Phone:718-836-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130065207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY238688Medicaid
NY238688Medicaid
NY314151Medicare ID - Type Unspecified