Provider Demographics
NPI:1578649059
Name:ALBA, JUAN ANDRES (MD,)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:ANDRES
Last Name:ALBA
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 1:332 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-2027
Mailing Address - Country:US
Mailing Address - Phone:201-944-8401
Mailing Address - Fax:
Practice Address - Street 1:29 WADSWORTH AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-7055
Practice Address - Country:US
Practice Address - Phone:212-928-1366
Practice Address - Fax:212-928-1368
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204149207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01754810Medicaid
NY01754810Medicaid