1386046191 NPI number — SAMUEL AUGUSTO DE YCAZA SINGH MD

Table of content: SAMUEL AUGUSTO DE YCAZA SINGH MD (NPI 1386046191)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386046191 NPI number — SAMUEL AUGUSTO DE YCAZA SINGH MD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
DE YCAZA SINGH

Provider First Name:
SAMUEL

Provider Middle Name:
AUGUSTO

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
MD

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386046191

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
05/06/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 BRAMPTON DR

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
DE WITT

Provider Business Mailing Address State Name:
NY

Provider Business Mailing Address Postal Code:
13214-1501

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
347-837-2553

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
736 IRVING AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
SYRACUSE

Provider Business Practice Location Address State Name:
NY

Provider Business Practice Location Address Postal Code:
13210-1687

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
315-470-7111

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
09/24/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 390200000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 207R00000X , with the licence number: 289678 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .