1104308634 NPI number — SANDRA PATRICIA ORTIZ QUINTERO

Table of content: SANDRA PATRICIA ORTIZ QUINTERO (NPI 1104308634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104308634 NPI number — SANDRA PATRICIA ORTIZ QUINTERO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTIZ QUINTERO
Provider First Name:
SANDRA
Provider Middle Name:
PATRICIA
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:
1104308634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10470 QUEENS BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11375-3694
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-275-6010
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10470 QUEENS BLVD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375-3694
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-275-6010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2018

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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