1205489937 NPI number — LIDYS MELISSA RODRIGUEZ MONTERROSA MD

Table of content: LIDYS MELISSA RODRIGUEZ MONTERROSA MD (NPI 1205489937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205489937 NPI number — LIDYS MELISSA RODRIGUEZ MONTERROSA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODRIGUEZ MONTERROSA
Provider First Name:
LIDYS
Provider Middle Name:
MELISSA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1205489937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14825 89TH AVE APT 2O
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMAICA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11435-3567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-437-9379
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10029-7491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-423-6229
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/22/2019

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10686 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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