Healthcare Provider Details

I. General information

NPI: 1023638012
Provider Name (Legal Business Name): SPORTS MEDICINE SPECIALIST P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1578 WILLIAMSBRIDGE RD # 3D
BRONX NY
10461-6265
US

IV. Provider business mailing address

3235 83RD ST
EAST ELMHURST NY
11370-2007
US

V. Phone/Fax

Practice location:
  • Phone: 347-418-6618
  • Fax:
Mailing address:
  • Phone: 347-418-6618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROMULO VASQUEZ
Title or Position: CEO
Credential: MD
Phone: 347-418-6618