Healthcare Provider Details

I. General information

NPI: 1275724767
Provider Name (Legal Business Name): BOSTON PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1262 BOSTON RD SUITE 1
BRONX NY
10456-3602
US

IV. Provider business mailing address

1262 BOSTON RD SUITE 1
BRONX NY
10456-3602
US

V. Phone/Fax

Practice location:
  • Phone: 718-617-2500
  • Fax: 718-617-0500
Mailing address:
  • Phone: 718-617-2500
  • Fax: 718-617-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number214716
License Number StateNY

VIII. Authorized Official

Name: DR. JORGE LUIS CORNIELLE
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 718-617-2500