Provider Demographics
NPI:1033300231
Name:SIROTIN, NICOLE ASHLEY (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ASHLEY
Last Name:SIROTIN
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 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:718-579-2500
Mailing Address - Fax:
Practice Address - Street 1:3611 21ST ST
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-4705
Practice Address - Country:US
Practice Address - Phone:718-482-7772
Practice Address - Fax:718-482-9648
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99651207R00000X
NY60 254310207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NYG100000410Medicare Oscar/Certification
NY331009Medicare Oscar/Certification