MEDICARE: MILDRED MARMOLEJOS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	212325	NY

General Provider Information

NPI Number	:	1316481278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MILDRED MARMOLEJOS

Provider Business Mailing Address
First Line	:	434 S 5TH ST
Second Line	:	APT 2
City	:	BROOKLYN
State	:	NY
Zip	:	11211-1727
Country	:	US
Telephone Number	:	917-692-7831
Fax Number	:

Provider Business Practice Location Address
First Line	:	434 S 5TH ST
Second Line	:	APT 2
City	:	BROOKLYN
State	:	NY
Zip	:	11211-1727
Country	:	US
Telephone Number	:	917-692-7831
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2016
Last Update Date	:	12/12/2016

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Directions to “ MILDRED MARMOLEJOS ” Practice Location

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