Provider Demographics
NPI:1124051313
Name:DUA, NIELS MANU (MD)
Entity type:Individual
Prefix:
First Name:NIELS
Middle Name:MANU
Last Name:DUA
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 1:3274 STEINWAY ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4006
Mailing Address - Country:US
Mailing Address - Phone:860-997-4957
Mailing Address - Fax:718-721-0122
Practice Address - Street 1:3274 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4006
Practice Address - Country:US
Practice Address - Phone:860-997-4957
Practice Address - Fax:718-721-0122
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2017-01-03
Deactivation Date:2006-07-19
Deactivation Code:
Reactivation Date:2006-09-07
Provider Licenses
StateLicense IDTaxonomies
NY211446207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02602308Medicaid
NY02602308Medicaid
H49207Medicare UPIN