Basic Information
| Provider Information | |||||||||
| NPI: | 1356323133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESILVA | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 GRAHAM RD W | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072572188 | ||||||||
| FaxNumber: | 6072667341 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 GRAHAM RD W | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072572188 | ||||||||
| FaxNumber: | 6072667341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 211165 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | V018315 | 01 | TRICARE | OTHER | 000910782001 | 01 | HEALTHNOW | OTHER | 5677620 | 01 | AETNA MANAGED CHOICE | OTHER | 6477 | 01 | NY | TOTAL CARE/MANAGED MA | OTHER | 01868340 | 05 | NY | MEDICAID |