Provider Demographics
NPI:1073778916
Name:EAW MEDICAL CARE PLLC
Entity Type:Organization
Organization Name:EAW MEDICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EVERTON
Authorized Official - Middle Name:
Authorized Official - Last Name:PROSPERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-207-6792
Mailing Address - Street 1:612 SCHENECTADY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1821
Mailing Address - Country:US
Mailing Address - Phone:917-207-6792
Mailing Address - Fax:
Practice Address - Street 1:612 SCHENECTADY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1821
Practice Address - Country:US
Practice Address - Phone:917-207-6792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226783207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100000916Medicare PIN