Provider Demographics
NPI:1558409110
Name:CEBALLOS, BIENVENIDO PONCARDAS JR (BSPT)
Entity Type:Individual
Prefix:MR
First Name:BIENVENIDO
Middle Name:PONCARDAS
Last Name:CEBALLOS
Suffix:JR
Gender:M
Credentials:BSPT
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Mailing Address - Street 1:15 MONMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-2514
Mailing Address - Country:US
Mailing Address - Phone:631-839-4061
Mailing Address - Fax:631-274-5940
Practice Address - Street 1:55 POST AVE
Practice Address - Street 2:STE 205
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-4361
Practice Address - Country:US
Practice Address - Phone:516-338-0412
Practice Address - Fax:516-338-1106
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY019520225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02330692Medicaid
NYQP9801Medicare ID - Type Unspecified