Provider Demographics
NPI:1346451929
Name:VANESSA PERO MEDICAL DIAGNOSTIC SERVICES PC
Entity Type:Organization
Organization Name:VANESSA PERO MEDICAL DIAGNOSTIC SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:THERESA
Authorized Official - Last Name:THERESA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-267-8196
Mailing Address - Street 1:365 MINEOLA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-1526
Mailing Address - Country:US
Mailing Address - Phone:718-267-8196
Mailing Address - Fax:
Practice Address - Street 1:458 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3123
Practice Address - Country:US
Practice Address - Phone:718-267-8196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167430207RC0000X
NY1673422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1174734859OtherINDIVIDUAL NPI