Basic Information
| Provider Information | |||||||||
| NPI: | 1457476350 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOISROND-CANAL | ||||||||
| FirstName: | CONSTANTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 FENIMORE AVE | ||||||||
| Address2: | |||||||||
| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115531513 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 WATERS PL | ||||||||
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| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104612723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189310600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 185374 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 185374 | 05 | NY | MEDICAID |