Basic Information
| Provider Information | |||||||||
| NPI: | 1043752041 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL QUEENS IPA,D/B/A SOUTH ASIAN IPA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH ASIAN IPA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7017 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113723922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186835467 | ||||||||
| FaxNumber: | 7185655686 | ||||||||
| Practice Location | |||||||||
| Address1: | 7017 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113723922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186835467 | ||||||||
| FaxNumber: | 7185655686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2016 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KHANDKER | ||||||||
| AuthorizedOfficialFirstName: | FERDOUS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 7186835467 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH ASIAN IPA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 225253 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02300407 | 05 | NY | MEDICAID |