Healthcare Provider Details

I. General information

NPI: 1447292578
Provider Name (Legal Business Name): CARLOS H. MONTOYA-IRAHETA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MINEOLA BLVD SUITE 210
MINEOLA NY
11501-4073
US

IV. Provider business mailing address

222 STATION PLZ N SUITE 611
MINEOLA NY
11501-3808
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-4600
  • Fax: 516-663-4473
Mailing address:
  • Phone: 516-663-2532
  • Fax: 516-663-2233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number188908
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number188908
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: