Provider Demographics
NPI:1538130547
Name:BERROYA, RENATO B (MD, FASC)
Entity Type:Individual
Prefix:DR
First Name:RENATO
Middle Name:B
Last Name:BERROYA
Suffix:
Gender:M
Credentials:MD, FASC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 PORT WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3733
Mailing Address - Country:US
Mailing Address - Phone:516-883-2212
Mailing Address - Fax:516-767-7064
Practice Address - Street 1:639 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3733
Practice Address - Country:US
Practice Address - Phone:516-883-2212
Practice Address - Fax:516-767-7064
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C11853Medicare UPIN
684361Medicare ID - Type Unspecified