Healthcare Provider Details

I. General information

NPI: 1679623409
Provider Name (Legal Business Name): MARCELO O POMARES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 SHAKESPEARE AVE
BRONX NY
10452-1851
US

IV. Provider business mailing address

2222 FISH AVE
BRONX NY
10469-5837
US

V. Phone/Fax

Practice location:
  • Phone: 718-538-6311
  • Fax: 718-538-5820
Mailing address:
  • Phone: 347-602-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200537
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: