Provider Demographics
NPI:1568455525
Name:ACEVEDO, JOSE A (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:ACEVEDO
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 1:128 FORT WASHINGTON AVE
Mailing Address - Street 2:STE D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-4735
Mailing Address - Country:US
Mailing Address - Phone:212-795-8666
Mailing Address - Fax:212-795-8688
Practice Address - Street 1:128 FORT WASHINGTON AVE
Practice Address - Street 2:STE D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-4735
Practice Address - Country:US
Practice Address - Phone:212-795-8666
Practice Address - Fax:212-795-8688
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1668682084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4396137OtherAETNA
NY00966216Medicaid
NY4396137OtherAETNA
NY82D151Medicare ID - Type Unspecified