1457709917 NPI number — MABEL MARBELLA GOMEZ MA IN MHC PERMIT

Table of content: MABEL MARBELLA GOMEZ MA IN MHC PERMIT (NPI 1457709917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457709917 NPI number — MABEL MARBELLA GOMEZ MA IN MHC PERMIT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMEZ
Provider First Name:
MABEL
Provider Middle Name:
MARBELLA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA IN MHC PERMIT
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:
1457709917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 THAYER ST APT D4
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:
10040-1042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-338-9007
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
579 COURTLANDT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10451-5013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-485-2100
Provider Business Practice Location Address Fax Number:
718-485-2101
Provider Enumeration Date:
05/25/2016

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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