Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 231667 | NY |
NPI | 1124201322 |
---|---|
Provider Name | Yudhistira Persaud |
First Address | Briarwood, NY 11435-3113 |
Second Address | Bronx, NY 10456-3402 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/12/2007 |
Last Update Date | 11/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
231667 | STATE LICENSE (01) | NY |