Provider Demographics
NPI:1376644591
Name:LAURETA, EMMA (MD)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:LAURETA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MA. EMMA CECILIA
Other - Middle Name:MILLAN
Other - Last Name:LAURETA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6751 182ND ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3505
Mailing Address - Country:US
Mailing Address - Phone:718-969-3001
Mailing Address - Fax:
Practice Address - Street 1:3415 BAINBRIDGE AVENUE AT GUNHILL ROAD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-4378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2465782084N0402X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02118376Medicaid
NYH31904Medicare UPIN
NY264Z01Medicare ID - Type Unspecified