Healthcare Provider Details

I. General information

NPI: 1811004120
Provider Name (Legal Business Name): JUAN P AMPUERO III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 PRESIDENTIAL DR
KINDERHOOK NY
12106-1712
US

IV. Provider business mailing address

6 PRESIDENTIAL DR
KINDERHOOK NY
12106-1712
US

V. Phone/Fax

Practice location:
  • Phone: 518-610-8310
  • Fax:
Mailing address:
  • Phone: 518-610-8310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA08072400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number251145
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: