Healthcare Provider Details

I. General information

NPI: 1992978654
Provider Name (Legal Business Name): GLORIA S ESCOBAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 ISLIP AVENUE SUITE 27
ISLIP NY
11751
US

IV. Provider business mailing address

148 ISLIP AVENUE SUITE 27
ISLIP NY
11751
US

V. Phone/Fax

Practice location:
  • Phone: 631-650-6580
  • Fax: 631-650-6578
Mailing address:
  • Phone: 631-650-6580
  • Fax: 631-650-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number249522
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number249544
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: