Healthcare Provider Details

I. General information

NPI: 1598856007
Provider Name (Legal Business Name): EDGAR ANDREW PIMENTEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 W 204TH ST
NEW YORK NY
10034-4008
US

IV. Provider business mailing address

143 REVILLE ST
BRONX NY
10464-1339
US

V. Phone/Fax

Practice location:
  • Phone: 212-567-3777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number203059
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: