Healthcare Provider Details

I. General information

NPI: 1982166989
Provider Name (Legal Business Name): ROBERTO R CABRAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 VILLAGE GRN UNIT A
PATCHOGUE NY
11772-3080
US

IV. Provider business mailing address

101 SAINT ANDREWS LN
GLEN COVE NY
11542-2254
US

V. Phone/Fax

Practice location:
  • Phone: 631-227-6665
  • Fax: 631-289-1046
Mailing address:
  • Phone: 516-674-7631
  • Fax: 516-674-7639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number286391
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: