Healthcare Provider Details

I. General information

NPI: 1922052703
Provider Name (Legal Business Name): MR. JOSEPH GUERRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2868 BROADWAY
NEW YORK NY
10025-7824
US

IV. Provider business mailing address

2868 BROADWAY
NEW YORK NY
10025-7824
US

V. Phone/Fax

Practice location:
  • Phone: 212-865-9825
  • Fax:
Mailing address:
  • Phone: 212-865-9825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number3744
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: