Provider Demographics
NPI:1497193221
Name:VAN UDEN, ALFONSO (ND)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:VAN UDEN
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 LATOURETTE LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6363
Mailing Address - Country:US
Mailing Address - Phone:347-858-1768
Mailing Address - Fax:
Practice Address - Street 1:9859 CORONA AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2783
Practice Address - Country:US
Practice Address - Phone:347-858-1768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYND100185 FEDERAL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist