1104987064 NPI number — DR. FABIO LEONIDAS URRESTA MD, MS

Table of content: DR. FABIO LEONIDAS URRESTA MD, MS (NPI 1104987064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104987064 NPI number — DR. FABIO LEONIDAS URRESTA MD, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
URRESTA
Provider First Name:
FABIO
Provider Middle Name:
LEONIDAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, MS
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:
1104987064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 NEWCASTLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HALFMOON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12065-6123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-724-5151
Provider Business Mailing Address Fax Number:
518-207-9078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 NEWCASTLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HALFMOON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12065-6123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-724-5151
Provider Business Practice Location Address Fax Number:
518-207-9078
Provider Enumeration Date:
12/13/2006

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: 2084P0800X , with the licence number:  247163 , 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: 05446216 . This is a "ECFMG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6022352 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0046572 . This is a "EMPIRE BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1891946323 . This is a "MEDICARE GROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 533029 . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 605560 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000417902002 . This is a "BLUE SHIELD OF NORTHEASTERN NEW YORKI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1104987064 . This is a "MEDICARE INDIVIDUAL" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com