Healthcare Provider Details

I. General information

NPI: 1134336597
Provider Name (Legal Business Name): LUCIO MALACO PEREIRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 LAKEVILLE RD
NEW HYDE PARK NY
11042-1121
US

IV. Provider business mailing address

5419 LINDEN CT
BETHESDA MD
20814-1643
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-7550
  • Fax:
Mailing address:
  • Phone: 313-909-7782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number287411-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number287411-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: