Healthcare Provider Details

I. General information

NPI: 1821176280
Provider Name (Legal Business Name): MINERVA SANTOS VICTORIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 ATLANTIC AVE
BROOKLYN NY
11213-1122
US

IV. Provider business mailing address

4701 88TH ST
ELMHURST NY
11373-3950
US

V. Phone/Fax

Practice location:
  • Phone: 718-613-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number121892
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: