Provider Demographics
NPI:1275507899
Name:PORQUEDDU, ASTRID SOPHIA
Entity Type:Individual
Prefix:MRS
First Name:ASTRID
Middle Name:SOPHIA
Last Name:PORQUEDDU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASTRID
Other - Middle Name:SOPHIA
Other - Last Name:CANTILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:42 EAGLE LANE
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756
Mailing Address - Country:US
Mailing Address - Phone:516-796-3842
Mailing Address - Fax:516-538-6785
Practice Address - Street 1:1 HELEN KELLER WAY
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550
Practice Address - Country:US
Practice Address - Phone:516-485-1234
Practice Address - Fax:516-538-6785
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005767152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT005767Medicaid
NYT005767Medicaid
NYC16311Medicare ID - Type Unspecified