Provider Demographics
NPI:1356313597
Name:GILLEGO, AZUCENA M (MD)
Entity Type:Individual
Prefix:MRS
First Name:AZUCENA
Middle Name:M
Last Name:GILLEGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:205-07 HILLSIDE AVE
Mailing Address - Street 2:STE 10
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423
Mailing Address - Country:US
Mailing Address - Phone:718-464-5780
Mailing Address - Fax:718-464-5781
Practice Address - Street 1:205-07 HILLSIDE AVE
Practice Address - Street 2:STE 10
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423
Practice Address - Country:US
Practice Address - Phone:718-464-5780
Practice Address - Fax:718-464-5781
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY159298207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00841061Medicaid
NY00841061Medicaid
B58730Medicare UPIN