Provider Demographics
NPI:1801891908
Name:BERDIA, AJAY V (MD)
Entity type:Individual
Prefix:
First Name:AJAY
Middle Name:V
Last Name:BERDIA
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 1:200 BELLE TERRE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1928
Mailing Address - Country:US
Mailing Address - Phone:631-474-6300
Mailing Address - Fax:631-474-6161
Practice Address - Street 1:640 BELLE TERRE ROAD, BUILDING H
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-0001
Practice Address - Country:US
Practice Address - Phone:631-474-1112
Practice Address - Fax:631-474-1112
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196859174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY130019918OtherRAIL ROAD MEDICARE
NY2190491OtherAETNA HEALTH PLANS
NY810620OtherFIRST HEALTH INSURANCE
NYP560221OtherOXFORD HEALTH PLANS
NY3099464OtherGHI HEALTH INSURANCE
NY087312OtherBLUE CROSS BLUE SHIELD
NY48613OtherVYTRA HEALTH PLANS
NY01524845Medicaid
NY196859OtherHIP HEALTH PLANS
NY087312OtherBLUE CROSS BLUE SHIELD
NYG02015Medicare UPIN