Healthcare Provider Details

I. General information

NPI: 1043209729
Provider Name (Legal Business Name): ERNESTO AQUIATAN NUEVA ESPANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 PALISADE AVE
RIVERDALE NY
10471-1214
US

IV. Provider business mailing address

159 OLD WILMOT RD
SCARSDALE NY
10583-6162
US

V. Phone/Fax

Practice location:
  • Phone: 718-581-1200
  • Fax: 718-581-1012
Mailing address:
  • Phone: 914-472-5937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number181822
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: