Provider Demographics
NPI:1376622019
Name:MEDIAVILLO, RENE S (MD)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:S
Last Name:MEDIAVILLO
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 1:9202 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417-1526
Mailing Address - Country:US
Mailing Address - Phone:718-835-9729
Mailing Address - Fax:718-925-9817
Practice Address - Street 1:9202 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-1526
Practice Address - Country:US
Practice Address - Phone:718-835-9729
Practice Address - Fax:718-925-9817
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136585174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY136585OtherLICENSE
NY00589464Medicaid