=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992875223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISABELITA CORDOBA,MDPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 11/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 564 BROADWAY
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002-3825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-436-8418
-----------------------------------------------------
Fax | 908-561-1803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 STRATFORD CIR
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08820-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-561-1803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ISABELITA YNIGO CORDOBA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 201-436-8418
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------