Ilham Derhan Putra

Primary specialty

Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X

License

337333-01 Issued in NY

Practice address

525 E 68TH St
New York, NY 10065-4870

Phone

(813) 789-3508

NPI assigned

Mar 24, 2020

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Pathology

Education

Other, 2013

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1585008000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1782345600000",
    "number": "1770110389",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "525 E 68TH ST",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100654870"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "525 E 68TH ST",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100654870",
            "telephone_number": "813-789-3508"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PUTRA",
        "first_name": "ILHAM",
        "middle_name": "DERHAN",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2020-03-24",
        "last_updated": "2026-06-25",
        "certification_date": "2026-06-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "NY",
            "license": "337333-01",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jennifer Pusztay
• Maria Putilina
• Claire Putman
• Isaiah David Putman
• Megan Anne Putnam, PH.D.
• Vinay Ganesh Puttanniah, M.D.
• Gina Brandeis Putter
• Avery B Putterman, CPNP
• Jill T. Putterman, PH.D.
• Melissa Erin Putterman

• Anatomic Pathology & Clinical Pathology Physician in New York, NY
• Providers in New York, NY by specialty
• Anatomic Pathology & Clinical Pathology Physician in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.