Healthcare Provider Details

I. General information

NPI: 1396815593
Provider Name (Legal Business Name): ALTAGRACIA B TOLENTINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 PROSPECT AVENUE CENTER FOR CHILDREN HEALTH AND RESILIENCY
BRONX NY
10459
US

IV. Provider business mailing address

2411 GUNTHER AVE
BRONX NY
10469-6245
US

V. Phone/Fax

Practice location:
  • Phone: 718-991-0605
  • Fax:
Mailing address:
  • Phone: 718-991-0605
  • Fax: 718-991-2931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number201735
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: