Provider Demographics
NPI:1164035200
Name:BELTRAN, FERNANDO EDGARDO JR
Entity Type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:EDGARDO
Last Name:BELTRAN
Suffix:JR
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 1:425 OLD TOWN RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3627
Mailing Address - Country:US
Mailing Address - Phone:631-209-7042
Mailing Address - Fax:
Practice Address - Street 1:425 OLD TOWN RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3627
Practice Address - Country:US
Practice Address - Phone:631-209-7042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101668-01104100000X
NY093837-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker