1609958321 NPI number — MR. DEMETRIO C CABRERA P.T.

Table of content: MR. DEMETRIO C CABRERA P.T. (NPI 1609958321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609958321 NPI number — MR. DEMETRIO C CABRERA P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CABRERA
Provider First Name:
DEMETRIO
Provider Middle Name:
C
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1609958321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 ORCHID DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MASTIC BEACH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11951-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-666-4600
Provider Business Mailing Address Fax Number:
631-666-4605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1766 SUNRISE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY SHORE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11706-6010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-666-4600
Provider Business Practice Location Address Fax Number:
631-666-4605
Provider Enumeration Date:
10/20/2006

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: 174400000X , with the licence number:  022429-1 , 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: 2582658 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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