MEDICARE: BRENTWOOD PEDIATRIC & ADOLESCENT ASSOCIATES, PC

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	2080A0000X	Pediatric Adolescent Medicine Physician	224588-1	NY

General Provider Information

NPI Number	:	1578753075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENTWOOD PEDIATRIC & ADOLESCENT ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	1464 5TH AVE
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-4147
Country	:	US
Telephone Number	:	631-231-5070
Fax Number	:	631-435-3288

Provider Business Practice Location Address
First Line	:	1464 5TH AVE
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-4147
Country	:	US
Telephone Number	:	631-231-5070
Fax Number	:	631-435-3288

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JUAN C ESPINOZA
Credential	:	M.D.
Telephone Number	:	631-231-5070

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	05/15/2015

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