Healthcare Provider Details

I. General information

NPI: 1861730046
Provider Name (Legal Business Name): JESUS ENMANUEL MOTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

234 E 149TH ST
BRONX NY
10451-5504
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5030
  • Fax:
Mailing address:
  • Phone: 718-579-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number276477
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: