Provider Demographics
NPI:1134284581
Name:SAN, MYAT (MD)
Entity type:Individual
Prefix:DR
First Name:MYAT
Middle Name:
Last Name:SAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SAINT NICHOLAS AVE
Mailing Address - Street 2:APT # 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-3474
Mailing Address - Country:US
Mailing Address - Phone:718-418-8368
Mailing Address - Fax:718-418-8716
Practice Address - Street 1:115 SAINT NICHOLAS AVE
Practice Address - Street 2:APT # 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-3474
Practice Address - Country:US
Practice Address - Phone:718-418-8368
Practice Address - Fax:718-418-8716
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231830174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01925768Medicaid
NY08223GMedicare PIN
NY01925768Medicaid
NY45C511Medicare PIN
NY45C518Medicare PIN