Provider Demographics
NPI:1609163716
Name:21ST AVENUE PRIMARY CARE PA
Entity Type:Organization
Organization Name:21ST AVENUE PRIMARY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:LEON-WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-925-5400
Mailing Address - Street 1:534 21ST AVE
Mailing Address - Street 2:PATERSON
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07513-1337
Mailing Address - Country:US
Mailing Address - Phone:973-925-5400
Mailing Address - Fax:973-925-5403
Practice Address - Street 1:534 21ST AVE
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07513-1337
Practice Address - Country:US
Practice Address - Phone:973-925-5400
Practice Address - Fax:973-925-5403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-09
Last Update Date:2011-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05907400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty