Provider Demographics
NPI:1053331371
Name:TAGLE, ELENITA (MD)
Entity Type:Individual
Prefix:
First Name:ELENITA
Middle Name:
Last Name:TAGLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 BERGEN TPKE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07660-2314
Mailing Address - Country:US
Mailing Address - Phone:201-641-5928
Mailing Address - Fax:
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-4408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155022207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01268524Medicaid
NY08E432Medicare ID - Type Unspecified
NYA60353Medicare UPIN