Provider Demographics
NPI:1508032954
Name:LIZ DEFILLO, VICENTE J (MD)
Entity Type:Individual
Prefix:DR
First Name:VICENTE
Middle Name:J
Last Name:LIZ DEFILLO
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 1:1295 5TH AVE
Mailing Address - Street 2:APT 33D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3134
Mailing Address - Country:US
Mailing Address - Phone:646-359-1012
Mailing Address - Fax:
Practice Address - Street 1:30 W 60TH ST
Practice Address - Street 2:APT 1F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7906
Practice Address - Country:US
Practice Address - Phone:646-359-1012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2704052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry