Provider Demographics
NPI:1114974623
Name:ASTUDILLO, LUIS MARIO (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:MARIO
Last Name:ASTUDILLO
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:PO BOX 837
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-0837
Mailing Address - Country:US
Mailing Address - Phone:718-562-6570
Mailing Address - Fax:718-346-5313
Practice Address - Street 1:3131 GRAND CONCOURSE
Practice Address - Street 2:SUITE 1B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-1442
Practice Address - Country:US
Practice Address - Phone:718-295-7900
Practice Address - Fax:718-295-4160
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243249207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA350518195AMedicaid
GA11BDXJSMedicare ID - Type Unspecified
GA350518195AMedicaid