Provider Demographics
NPI:1679529911
Name:JASTY, SUSMITA (MD)
Entity type:Individual
Prefix:
First Name:SUSMITA
Middle Name:
Last Name:JASTY
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 1:1630 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1104
Mailing Address - Country:US
Mailing Address - Phone:718-258-3712
Mailing Address - Fax:718-257-4940
Practice Address - Street 1:9413 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236
Practice Address - Country:US
Practice Address - Phone:718-258-3712
Practice Address - Fax:718-257-4940
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153709207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00766069Medicaid
NY95A281Medicare PIN