Provider Demographics
NPI:1962674184
Name:MARIWALLA, KAVITA (MD)
Entity Type:Individual
Prefix:DR
First Name:KAVITA
Middle Name:
Last Name:MARIWALLA
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 1:1253 MONTAUK HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4916
Mailing Address - Country:US
Mailing Address - Phone:631-665-3376
Mailing Address - Fax:631-969-3376
Practice Address - Street 1:1253 MONTAUK HIGHWAY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4916
Practice Address - Country:US
Practice Address - Phone:631-665-3376
Practice Address - Fax:631-969-3370
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046352207N00000X, 207ND0101X
NY253189207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology