Healthcare Provider Details

I. General information

NPI: 1760455497
Provider Name (Legal Business Name): EVELYN LLANOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date: 10/10/2007
Reactivation Date: 10/24/2007

III. Provider practice location address

19 SOUTHDOWN RD
HUNTINGTON NY
11743-2538
US

IV. Provider business mailing address

19 SOUTHDOWN RD
HUNTINGTON NY
11743
US

V. Phone/Fax

Practice location:
  • Phone: 631-470-2572
  • Fax: 631-423-9276
Mailing address:
  • Phone: 631-470-2572
  • Fax: 631-385-1748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2381051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: