1174669048 NPI number — DR. FREDERICK ANTHONY BEVELAQUA M.D.

Table of content: DR. FREDERICK ANTHONY BEVELAQUA M.D. (NPI 1174669048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174669048 NPI number — DR. FREDERICK ANTHONY BEVELAQUA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEVELAQUA
Provider First Name:
FREDERICK
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1174669048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 A EAST 35TH ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-213-6796
Provider Business Mailing Address Fax Number:
212-213-4059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 A EAST 35TH ST.
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:
10016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-213-6796
Provider Business Practice Location Address Fax Number:
212-213-4059
Provider Enumeration Date:
01/29/2007

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: 207RP1001X , with the licence number:  126040 , 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)





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