Basic Information
| Provider Information | |||||||||
| NPI: | 1154399111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOHAL | ||||||||
| FirstName: | AJENDRA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 HEMPSTEAD TPKE | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115541859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165726525 | ||||||||
| FaxNumber: | 5165723170 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 HEMPSTEAD TPKE | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115541859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165726525 | ||||||||
| FaxNumber: | 5165723170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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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 | 208100000X | 189088 | NY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | 189088 | NY | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01464135 | 05 | NY | MEDICAID |