Individual
AINIE SOETANTO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
111 E 210TH ST, BRONX, NY 10467-2401
(718) 920-2625
Mailing address
111 E 210TH ST, BRONX, NY 10467-2401
(718) 920-2625
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
289406
NY
2084V0102X
Vascular Neurology Physician
289406
NY
390200000X
Student in an Organized Health Care Education/Training Program
26938410
PA
Other
Enumeration date
06/27/2013
Last updated
04/30/2025
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