Basic Information
| Provider Information | |||||||||
| NPI: | 1134172018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEUKJIAN | ||||||||
| FirstName: | VAHE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2000 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188288363 | ||||||||
| FaxNumber: | 5186973388 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 PROSPECT AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188283327 | ||||||||
| FaxNumber: | 5186978158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 05/07/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1-190528 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 141483 | 01 | WELLCARE | OTHER | 01374556 | 05 | NY | MEDICAID | 16L472 | 01 | BC/BS | OTHER | 10031632 | 01 | CDPHP | OTHER | 9600083 | 01 | GHI PPO | OTHER | 1924404 | 01 | UNITED HEALTH CARE | OTHER | 000492005001 | 01 | BSNENY | OTHER | 26734 | 01 | GHI HMO | OTHER | 040426007279 | 01 | FIDELIS | OTHER | 080139873 | 01 | RAILROAD MEDICARE | OTHER | 087225 | 01 | MVP | OTHER |