Provider Demographics
NPI:1780870279
Name:PATHAK INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:PATHAK INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATHAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-857-6743
Mailing Address - Street 1:181 DOGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-3005
Mailing Address - Country:US
Mailing Address - Phone:516-801-2530
Mailing Address - Fax:
Practice Address - Street 1:3400 BRUSH HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-1712
Practice Address - Country:US
Practice Address - Phone:516-857-6743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231995174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG95214Medicare UPIN