Basic Information
| Provider Information | |||||||||
| NPI: | 1124201322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERSAUD | ||||||||
| FirstName: | YUDHISTIRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14833 87TH RD | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114353113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175846770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1276 FULTON AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104563402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185901800 | ||||||||
| FaxNumber: | 7185185124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2007 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | 231667 | NY | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
| ID | Type | State | Issuer | Description | 231667 | 01 | NY | STATE LICENSE | OTHER |