Provider Demographics
NPI:1366976508
Name:KURUVILLA, AMY ELIZABETH
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:KURUVILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 SNEDECKER AVE
Mailing Address - Street 2:
Mailing Address - City:CONGERS
Mailing Address - State:NY
Mailing Address - Zip Code:10920-1806
Mailing Address - Country:US
Mailing Address - Phone:845-480-4706
Mailing Address - Fax:
Practice Address - Street 1:5645 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:845-480-4706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY307398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program