Provider Demographics
NPI:1275693012
Name:TALAVERA, WILFREDO (MD)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:TALAVERA
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 1:148 W 23RD ST
Mailing Address - Street 2:APT 12-B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-2435
Mailing Address - Country:US
Mailing Address - Phone:917-622-7137
Mailing Address - Fax:
Practice Address - Street 1:160 W 26TH ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-6975
Practice Address - Country:US
Practice Address - Phone:646-660-9999
Practice Address - Fax:646-778-3485
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133330207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5068801Medicaid
NY00727468Medicaid
NY74A69100Medicare ID - Type Unspecified
NY00727468Medicaid