Basic Information
| Provider Information | |||||||||
| NPI: | 1053302711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRASTA | ||||||||
| FirstName: | JOVITA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HEALTHY WAY | ||||||||
| Address2: | ATT PHYSICIAN BILLING -CREDENTIALS | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115721551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162551616 | ||||||||
| FaxNumber: | 5162554672 | ||||||||
| Practice Location | |||||||||
| Address1: | 2277 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115103148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163775400 | ||||||||
| FaxNumber: | 5163775490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 05/12/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | NY167156 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00245496 | 05 | NY | MEDICAID |