Basic Information
| Provider Information | |||||||||
| NPI: | 1861494908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAKAM | ||||||||
| FirstName: | SASHI | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2 COATES DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456511400 | ||||||||
| FaxNumber: | 8456511512 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 OAKWOOD TER STE 100 | ||||||||
| Address2: | |||||||||
| City: | NEW WINDSOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125537754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455611270 | ||||||||
| FaxNumber: | 8455611428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 203585 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | A400038077 | 01 | MEDICARE | OTHER | 01682159 | 05 | NY | MEDICAID |