Healthcare Provider Details

I. General information

NPI: 1144283458
Provider Name (Legal Business Name): JOSE CERVANTES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13420 JAMAICA AVE
JAMAICA NY
11418-2619
US

IV. Provider business mailing address

80 MARCUS DR PROVIDER ENROLLMENT
MELVILLE NY
11747-4230
US

V. Phone/Fax

Practice location:
  • Phone: 718-206-6742
  • Fax: 718-206-6905
Mailing address:
  • Phone: 631-391-7889
  • Fax: 631-454-4161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number159085
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number159085
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: