Healthcare Provider Details

I. General information

NPI: 1811332836
Provider Name (Legal Business Name): MIGUEL LORENZO SILVA LITAO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

498 ESSEX ST STE 105
BANGOR ME
04401-3990
US

IV. Provider business mailing address

43 WESTMINSTER AVE
BERGENFIELD NJ
07621-3913
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-7744
  • Fax:
Mailing address:
  • Phone: 201-387-1957
  • Fax: 201-387-1036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number285351
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number285351
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: