Provider Demographics
NPI:1972609600
Name:NISCHAL, SANJEEV (MD,DABFM)
Entity type:Individual
Prefix:DR
First Name:SANJEEV
Middle Name:
Last Name:NISCHAL
Suffix:
Gender:M
Credentials:MD,DABFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608A JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4512
Mailing Address - Country:US
Mailing Address - Phone:516-499-6963
Mailing Address - Fax:516-352-0740
Practice Address - Street 1:608A JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4512
Practice Address - Country:US
Practice Address - Phone:516-499-6963
Practice Address - Fax:516-352-0740
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02810979Medicaid
NY267B2Y8201Medicare PIN
NY267B232781Medicare PIN