Provider Demographics
NPI:1730234097
Name:AZRA T WASTI PHYSICIAN PC
Entity type:Organization
Organization Name:AZRA T WASTI PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AZRA
Authorized Official - Middle Name:TABASSUM
Authorized Official - Last Name:WASTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-859-5171
Mailing Address - Street 1:834 CONEY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-5310
Mailing Address - Country:US
Mailing Address - Phone:718-859-5171
Mailing Address - Fax:718-469-0111
Practice Address - Street 1:834 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-5310
Practice Address - Country:US
Practice Address - Phone:718-859-5171
Practice Address - Fax:718-469-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189994208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty