Basic Information
Provider Information | |||||||||
NPI: | 1790748374 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOVIND | ||||||||
FirstName: | PRASHIL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 80 MARCUS DR | ||||||||
Address2: | PROVIDER ENROLLMENT | ||||||||
City: | MELVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 117474230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6313917889 | ||||||||
FaxNumber: | 6314544161 | ||||||||
Practice Location | |||||||||
Address1: | 14601 45TH AVE | ||||||||
Address2: | ROOM 407 | ||||||||
City: | FLUSHING | ||||||||
State: | NY | ||||||||
PostalCode: | 113552200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186705213 | ||||||||
FaxNumber: | 7183216004 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 01/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 225790 | NY | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0006X | 225790 | NY | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 02370212 | 05 | NY |   | MEDICAID |