Healthcare Provider Details

I. General information

NPI: 1679847008
Provider Name (Legal Business Name): URANTIA MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 NORTHERN BLVD SUITE 20
MANHASSET NY
11030-3035
US

IV. Provider business mailing address

1295 NORTHERN BLVD
MANHASSET NY
11030-3035
US

V. Phone/Fax

Practice location:
  • Phone: 516-365-4040
  • Fax:
Mailing address:
  • Phone: 516-365-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1818101
License Number StateNY

VIII. Authorized Official

Name: MODESTO FONTANEZ
Title or Position: PRINCIPAL
Credential: M.D.
Phone: 516-365-4040