Healthcare Provider Details

I. General information

NPI: 1366616047
Provider Name (Legal Business Name): INGRID CAROLINA MADERO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: INGRID CAROLINA HERNANDEZ SELMAN MD

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 COULTER RD FL 2
CLIFTON SPRINGS NY
14432-1122
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 315-462-2000
  • Fax: 315-462-6373
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number264272
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number264272
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: