Provider Demographics
NPI:1861563652
Name:BISANGWA, ALEXIS (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:
Last Name:BISANGWA
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 1:8920 LYMAN ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1406
Mailing Address - Country:US
Mailing Address - Phone:917-923-7091
Mailing Address - Fax:718-454-0736
Practice Address - Street 1:4359 147TH ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1739
Practice Address - Country:US
Practice Address - Phone:718-454-0735
Practice Address - Fax:718-454-0736
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2127692084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY526404OtherVALUE OPTIONS MHS NUMBER
NY01996721Medicaid
NY01996721Medicaid