Provider Demographics
NPI:1992097448
Name:MONDESIRE-CRUMP, IJAH (MD)
Entity type:Individual
Prefix:MR
First Name:IJAH
Middle Name:
Last Name:MONDESIRE-CRUMP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:IJAH
Other - Middle Name:MONDESIRE
Other - Last Name:CRUMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:50 E 98TH ST # 3F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6552
Mailing Address - Country:US
Mailing Address - Phone:917-312-1973
Mailing Address - Fax:
Practice Address - Street 1:1000 TENTH AVENUE, SUITE 2B-10
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-523-6970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No282N00000XHospitalsGeneral Acute Care Hospital