1134117476 NPI number — JOHN R TRINIDAD DPM

Table of content: JOHN R TRINIDAD DPM (NPI 1134117476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134117476 NPI number — JOHN R TRINIDAD DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRINIDAD
Provider First Name:
JOHN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1134117476
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
193 GREENE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAYVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11782-3002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-589-1706
Provider Business Mailing Address Fax Number:
631-218-1863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
193 GREENE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAYVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11782-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-589-1706
Provider Business Practice Location Address Fax Number:
631-218-1863
Provider Enumeration Date:
10/11/2005

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: 213E00000X , with the licence number:  N002883 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P3201 . This is a "BC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00400189 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".