Healthcare Provider Details

I. General information

NPI: 1942532791
Provider Name (Legal Business Name): ECHENIQUE MEDICAL OFFICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41-15 162ND STREET
FLUSHING NY
11358-4124
US

IV. Provider business mailing address

41-15 162ND STREET
FLUSHING NY
11358-4124
US

V. Phone/Fax

Practice location:
  • Phone: 718-762-6640
  • Fax: 718-762-6635
Mailing address:
  • Phone: 718-762-6640
  • Fax: 718-762-6635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number212182
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. EVELIO ECHENIQUE
Title or Position: PRESIDENT
Credential: MD
Phone: 718-762-6640