Healthcare Provider Details

I. General information

NPI: 1518382696
Provider Name (Legal Business Name): EGUOLO GEORGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WEBSTER AVE ROOM 107
BRONX NY
10457-8059
US

IV. Provider business mailing address

1600 WEBSTER AVE ROOM 107
BRONX NY
10457-8059
US

V. Phone/Fax

Practice location:
  • Phone: 718-731-0308
  • Fax: 718-731-0308
Mailing address:
  • Phone: 718-731-0308
  • Fax: 718-731-0308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number615372
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: