Provider Demographics
NPI:1184998858
Name:PRUTHI, SANDEEP (MD)
Entity type:Individual
Prefix:
First Name:SANDEEP
Middle Name:
Last Name:PRUTHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-2202
Mailing Address - Country:US
Mailing Address - Phone:914-236-4121
Mailing Address - Fax:914-709-4858
Practice Address - Street 1:41 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-2202
Practice Address - Country:US
Practice Address - Phone:914-236-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-28
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY277844208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA113368OtherSID # 113368