Provider Demographics
NPI:1316934524
Name:FAY MIZUE OHSUMI, MD PLLC
Entity type:Organization
Organization Name:FAY MIZUE OHSUMI, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:FAY
Authorized Official - Middle Name:MIZUE
Authorized Official - Last Name:OHSUMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-288-8121
Mailing Address - Street 1:117 E 84TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0902
Mailing Address - Country:US
Mailing Address - Phone:212-288-8121
Mailing Address - Fax:212-288-6311
Practice Address - Street 1:117 E 84TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0902
Practice Address - Country:US
Practice Address - Phone:212-288-8121
Practice Address - Fax:212-288-6311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167316207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01768625Medicaid
NYG57274Medicare UPIN
NYW7L641Medicare PIN