1386602027 NPI number — DR. SHIBU KINATUKARA DPM

Table of content: DR. SHIBU KINATUKARA DPM (NPI 1386602027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386602027 NPI number — DR. SHIBU KINATUKARA DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINATUKARA
Provider First Name:
SHIBU
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386602027
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1977 RALPH AVE STE 418
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11234-5416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-258-4100
Provider Business Mailing Address Fax Number:
718-251-1122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 OCEAN AVE
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11230-4963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-258-4100
Provider Business Practice Location Address Fax Number:
718-251-1856
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  NOO5595 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2287975 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6299162 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4695 . This is a "GHI MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2205136 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0051331 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P2743644 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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