Basic Information
| Provider Information | |||||||||
| NPI: | 1386681021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISTRY | ||||||||
| FirstName: | MAGANLAL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 441 9TH AVE | ||||||||
| Address2: | CREDENTIALING 3RD FL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100011623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802894 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 3245 NOSTRAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112293716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186153777 | ||||||||
| FaxNumber: | 7186153404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
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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 | 207RX0202X | 1405871 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00675136 | 05 | NY | MEDICAID |