=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518352244
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINCENT BRUZOLA DECHAVEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2015
-----------------------------------------------------
Last Update Date | 08/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 242 MASON AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10305-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 182-268-7167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8062 87TH AVE
-----------------------------------------------------
City | WOODHAVEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11421-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-515-9762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 304191-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 304191
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------