Healthcare Provider Details

I. General information

NPI: 1891746368
Provider Name (Legal Business Name): BOULEVARD MEDICAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4238 BRONX BLVD
BRONX NY
10466-2611
US

IV. Provider business mailing address

4238 BRONX BLVD
BRONX NY
10466-2611
US

V. Phone/Fax

Practice location:
  • Phone: 718-743-7090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number177458
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number151941
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number130048
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number106848
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number105455
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number206326
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number123469
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number109441
License Number StateNY
# 9
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number170475
License Number StateNY
# 10
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number120111
License Number StateNY
# 11
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN003013
License Number StateNY

VIII. Authorized Official

Name: LOUIS DIFAZIO
Title or Position: PARTNER
Credential:
Phone: 718-325-9532