Healthcare Provider Details

I. General information

NPI: 1306236468
Provider Name (Legal Business Name): DIEGO OQUENDO SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 W 50TH ST
NEW YORK NY
10020-1201
US

IV. Provider business mailing address

321B JERSEY ST
STATEN ISLAND NY
10301-2229
US

V. Phone/Fax

Practice location:
  • Phone: 212-582-9100
  • Fax:
Mailing address:
  • Phone: 517-803-5365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: