Provider Demographics
NPI:1386742419
Name:PATNAIK, ASHA LATA (MD)
Entity type:Individual
Prefix:DR
First Name:ASHA
Middle Name:LATA
Last Name:PATNAIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 RESEARCH WAY
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3526
Mailing Address - Country:US
Mailing Address - Phone:631-444-0580
Mailing Address - Fax:631-444-0562
Practice Address - Street 1:26 RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733
Practice Address - Country:US
Practice Address - Phone:631-444-0580
Practice Address - Fax:631-444-0562
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5898207R00000X
OH35-090755207R00000X
OH35.090755208M00000X
NY263442207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6005490Medicaid
OH35-090755OtherLICENSE
SD5898OtherLICENSE
SDS101273Medicare PIN
OH35-090755OtherLICENSE