Provider Demographics
NPI:1346276318
Name:ACEVEDO, EDWARD
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:ACEVEDO
Suffix:
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 1:4158 JUDGE ST
Mailing Address - Street 2:SUITE B1
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2400
Mailing Address - Country:US
Mailing Address - Phone:718-533-8029
Mailing Address - Fax:
Practice Address - Street 1:4158 JUDGE ST
Practice Address - Street 2:SUITE B1
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-2400
Practice Address - Country:US
Practice Address - Phone:718-533-8029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006707111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01804517Medicaid
U55982Medicare UPIN
NY01804517Medicaid