Provider Demographics
NPI:1457741035
Name:RAJESH MARIWALLA, MD PC
Entity Type:Organization
Organization Name:RAJESH MARIWALLA, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJESH
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIWALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-422-9600
Mailing Address - Street 1:1175 MONTAUK HWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4939
Mailing Address - Country:US
Mailing Address - Phone:631-422-9600
Mailing Address - Fax:631-422-9697
Practice Address - Street 1:1175 MONTAUK HWY
Practice Address - Street 2:SUITE 4
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4939
Practice Address - Country:US
Practice Address - Phone:631-422-9600
Practice Address - Fax:631-422-9697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153786208000000X
NY217202208000000X
NY209194208000000X
NY008888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty