Provider Demographics
NPI:1174669048
Name:BEVELAQUA, FREDERICK ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:ANTHONY
Last Name:BEVELAQUA
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 1:35 A EAST 35TH ST.
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:212-213-6796
Mailing Address - Fax:212-213-4059
Practice Address - Street 1:35 A EAST 35TH ST.
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-213-6796
Practice Address - Fax:212-213-4059
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126040207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY25A781Medicare ID - Type UnspecifiedMEDICARE
NYB11547Medicare UPIN