Provider Demographics
NPI:1093724973
Name:DEJESUS, UMBERTO J (PA)
Entity Type:Individual
Prefix:MR
First Name:UMBERTO
Middle Name:J
Last Name:DEJESUS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E 26TH ST APT 11B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-1910
Mailing Address - Country:US
Mailing Address - Phone:212-679-8853
Mailing Address - Fax:212-679-1666
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:BRONX LEBANON HOSPITAL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-960-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006533-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5296L1Medicare ID - Type Unspecified
NYQ11054Medicare UPIN