1811041155 NPI number — CEFERINO REYES VILLA FUERTE JR. MD

Table of content: CEFERINO REYES VILLA FUERTE JR. MD (NPI 1811041155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811041155 NPI number — CEFERINO REYES VILLA FUERTE JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VILLA FUERTE
Provider First Name:
CEFERINO
Provider Middle Name:
REYES
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VILLA FUERTE
Provider Other First Name:
CEFERINO
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MDP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1811041155
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 220
Provider Second Line Business Mailing Address:
133 EAST MAIN ST
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-677-5723
Provider Business Mailing Address Fax Number:
518-677-5723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 SMITH DRIVE
Provider Second Line Business Practice Location Address:
ADIRONDACK CLINIC
Provider Business Practice Location Address City Name:
CORINTH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-654-7680
Provider Business Practice Location Address Fax Number:
518-654-7693
Provider Enumeration Date:
01/23/2007

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: 208D00000X , with the licence number:  NY105492 , 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: 00358310 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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