Healthcare Provider Details

I. General information

NPI: 1245408970
Provider Name (Legal Business Name): JOSE GORIS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 FORT WASHINGTON AVENUE #1C
NEW YORK NY
10033
US

IV. Provider business mailing address

40 PROSPECT STREET
MONROE NY
10950
US

V. Phone/Fax

Practice location:
  • Phone: 212-923-0408
  • Fax: 212-923-4032
Mailing address:
  • Phone: 845-238-2168
  • Fax: 212-923-4032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number0050751
License Number StateNY

VIII. Authorized Official

Name: LUIS BLANCO
Title or Position: PHYSICIAN ASSISTANT
Credential: RPAC
Phone: 212-923-0408