Healthcare Provider Details

I. General information

NPI: 1114097607
Provider Name (Legal Business Name): JUAN CARLOS ESPINOZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 WICKS RD
BRENTWOOD NY
11717-4213
US

IV. Provider business mailing address

233 OLD TOWN RD
SETAUKET NY
11733-2604
US

V. Phone/Fax

Practice location:
  • Phone: 631-231-5070
  • Fax:
Mailing address:
  • Phone: 631-689-2314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number224588-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: