Provider Demographics
NPI:1518102987
Name:L&L CERVANTES MEDICAL PC
Entity Type:Organization
Organization Name:L&L CERVANTES MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:LOBER
Authorized Official - Middle Name:
Authorized Official - Last Name:CERVANTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-952-6397
Mailing Address - Street 1:7558 113TH ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7427
Mailing Address - Country:US
Mailing Address - Phone:917-952-6397
Mailing Address - Fax:
Practice Address - Street 1:4322 50TH ST
Practice Address - Street 2:2C
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4442
Practice Address - Country:US
Practice Address - Phone:718-424-9292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234737174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02646399Medicaid
NY234737OtherLICENSE