Provider Demographics
NPI:1043254865
Name:ITHARAT, PRASERT (MD)
Entity type:Individual
Prefix:
First Name:PRASERT
Middle Name:
Last Name:ITHARAT
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:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10703-0998
Mailing Address - Country:US
Mailing Address - Phone:914-966-9787
Mailing Address - Fax:914-966-9793
Practice Address - Street 1:2 PARK AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10703-3402
Practice Address - Country:US
Practice Address - Phone:914-966-9787
Practice Address - Fax:914-966-9793
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127385208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00466995Medicaid
NY00466995Medicaid
NY31A491Medicare PIN
NYB126989Medicare UPIN