MEDICARE: JOSE DARIO OVALLE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	009185	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013124627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE DARIO OVALLE PA

Provider Business Mailing Address
First Line	:	102 -11 ROOSEVELT AVE.
Second Line	:
City	:	CORONA
State	:	NY
Zip	:	11368-2331
Country	:	US
Telephone Number	:	718-989-5200
Fax Number	:	718-898-3673

Provider Business Practice Location Address
First Line	:	102 11 ROOSEVELT AVE.
Second Line	:
City	:	CORONA
State	:	NY
Zip	:	11368-2331
Country	:	US
Telephone Number	:	717-898-5200
Fax Number	:	718-898-3673

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/09/2007

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Directions to “ JOSE DARIO OVALLE PA” Practice Location

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