Provider Demographics
NPI:1114035193
Name:MEJIA, MANUEL ELIGIO (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:ELIGIO
Last Name:MEJIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 REISS PL APT 3M
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-8048
Mailing Address - Country:US
Mailing Address - Phone:347-387-3379
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-960-1443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241121207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY255SH79231Medicare PIN
NYI61370Medicare UPIN