Healthcare Provider Details

I. General information

NPI: 1558333724
Provider Name (Legal Business Name): LUIS ANTHONY GOYCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 60TH ST
WEST NEW YORK NJ
07093
US

IV. Provider business mailing address

228 60TH ST
WEST NEW YORK NJ
07093
US

V. Phone/Fax

Practice location:
  • Phone: 201-868-1120
  • Fax: 201-868-5801
Mailing address:
  • Phone: 201-868-1120
  • Fax: 201-868-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA04150300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: