Basic Information
| Provider Information | |||||||||
| NPI: | 1609804319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIN | ||||||||
| FirstName: | MAIRAJ | ||||||||
| MiddleName: | UD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 441 9TH AVE | ||||||||
| Address2: | ACP-CREDEMTIALING | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100011623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802894 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 AXINN AVE | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115302139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802894 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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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 | 207R00000X | 42496 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 786187700 | 05 | MN | MEDICAID |