Healthcare Provider Details

I. General information

NPI: 1710121991
Provider Name (Legal Business Name): SHIRLEY SOSTRE-OQUENDO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SUMMIT AVE
HACKENSACK NJ
07601-1503
US

IV. Provider business mailing address

450 SUMMIT AVE
HACKENSACK NJ
07601-1503
US

V. Phone/Fax

Practice location:
  • Phone: 201-294-1245
  • Fax:
Mailing address:
  • Phone: 201-294-1245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number25MA0940340
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: