1972276285 NPI number — VALESSA MESIDOR

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972276285 NPI number — VALESSA MESIDOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MESIDOR
Provider First Name:
VALESSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1972276285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32 COLUMBIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11735-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-921-5910
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 WANTAGH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WANTAGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11793-2257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-308-7405
Provider Business Practice Location Address Fax Number:
516-308-7404
Provider Enumeration Date:
08/01/2021

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: 363LP2300X , with the licence number:  347927-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 347927-01 , 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: 347927 . This is a "STATE LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 06885978 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: A400330312 . This is a "MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com