MEDICARE: MARILYN HUAMANTLA MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	322259	NY

General Provider Information

NPI Number	:	1720607823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN HUAMANTLA MD

Provider Business Mailing Address
First Line	:	503 S BROADWAY STE 210
Second Line	:
City	:	YONKERS
State	:	NY
Zip	:	10705-6202
Country	:	US
Telephone Number	:	914-965-9783
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 S BROADWAY STE 210
Second Line	:
City	:	YONKERS
State	:	NY
Zip	:	10705-6202
Country	:	US
Telephone Number	:	914-965-9783
Fax Number	:

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

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	06/28/2023

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