Provider Demographics
NPI:1194100537
Name:PUTHETHUKUDI GEORGE, DIMPLE (N P)
Entity type:Individual
Prefix:
First Name:DIMPLE
Middle Name:
Last Name:PUTHETHUKUDI GEORGE
Suffix:
Gender:F
Credentials:N P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 DARE RD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2004
Mailing Address - Country:US
Mailing Address - Phone:631-428-1645
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL ROAD
Practice Address - Street 2:BROOK HAVEN HOSPITAL MEDICAL CENTER
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-654-7214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307244363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health