Provider Demographics
NPI:1457554768
Name:QUEENS ARTHROSCOPY & SPORTS MEDICINE
Entity type:Organization
Organization Name:QUEENS ARTHROSCOPY & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAXMIDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DIWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-271-7700
Mailing Address - Street 1:62 54 97TH PLACE
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:718-271-7700
Mailing Address - Fax:718-271-4490
Practice Address - Street 1:6254 97TH PL
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1346
Practice Address - Country:US
Practice Address - Phone:718-271-7700
Practice Address - Fax:718-271-4490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153779207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY074942CMedicare ID - Type UnspecifiedGHI MEDICARE