Basic Information
| Provider Information | |||||||||
| NPI: | 1770756108 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ONE | ||||||||
| FirstName: | SAI | ||||||||
| MiddleName: | SI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5616 - 6TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184395440 | ||||||||
| FaxNumber: | 7184396401 | ||||||||
| Practice Location | |||||||||
| Address1: | 5616 - 6TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184395440 | ||||||||
| FaxNumber: | 7185679772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
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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 | 207Q00000X | 257764 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03247692 | 05 | NY | MEDICAID | 257764 | 01 | NY | LICENSE | OTHER |