Basic Information
| Provider Information | |||||||||
| NPI: | 1871546812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GURAM | ||||||||
| FirstName: | MOHINDER | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WATER ST | ||||||||
| Address2: | 2ND FLOOR CRED DEPT | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100410004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802888 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 HAWKINS AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE RONKONKOMA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117792324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317370100 | ||||||||
| FaxNumber: | 6314171117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
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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 | 208000000X | 161456 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01352854 | 05 | NY | MEDICAID |