Healthcare Provider Details

I. General information

NPI: 1336397686
Provider Name (Legal Business Name): J. R. UDARBE MD P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 NORTHERN BLVD SUITE 208
GREAT NECK NY
11021-5306
US

IV. Provider business mailing address

1010 NORTHERN BLVD SUITE 208
GREAT NECK NY
11021-5306
US

V. Phone/Fax

Practice location:
  • Phone: 516-336-2560
  • Fax: 516-336-2561
Mailing address:
  • Phone: 516-336-2560
  • Fax: 516-336-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number208198
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number208198
License Number StateNY

VIII. Authorized Official

Name: DR. JOHN ROBERT UDARBE
Title or Position: ATTENDING PHYSICIAN
Credential: M.D.
Phone: 516-336-2560