Provider Demographics
NPI:1083102008
Name:APENTENG, MAXWELL
Entity Type:Individual
Prefix:MR
First Name:MAXWELL
Middle Name:
Last Name:APENTENG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1248 E 224TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-5806
Mailing Address - Country:US
Mailing Address - Phone:347-202-7407
Mailing Address - Fax:347-202-7407
Practice Address - Street 1:1248 E 224TH ST APT 2
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-5806
Practice Address - Country:US
Practice Address - Phone:347-202-7407
Practice Address - Fax:347-202-7407
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY685381261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY805082191OtherSTATE ID