Healthcare Provider Details

I. General information

NPI: 1275672008
Provider Name (Legal Business Name): REMEDIOS VALENCIA MENDEGORIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 CROOKED HILL RD
W BRENTWOOD NY
11717-1043
US

IV. Provider business mailing address

90 ROSE DR
EAST MEADOW NY
11554-1134
US

V. Phone/Fax

Practice location:
  • Phone: 631-761-3500
  • Fax: 631-761-3630
Mailing address:
  • Phone: 516-794-5739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number157276
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: