Provider Demographics
NPI:1609850296
Name:SERRUYA, JOSE I (MDPC)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:I
Last Name:SERRUYA
Suffix:
Gender:M
Credentials:MDPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6907 43RD AVE
Mailing Address - Street 2:SUITE C 2
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-9100
Mailing Address - Country:US
Mailing Address - Phone:718-830-3772
Mailing Address - Fax:718-255-1841
Practice Address - Street 1:6907 43RD AVE
Practice Address - Street 2:SUITE C 2
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-9100
Practice Address - Country:US
Practice Address - Phone:718-830-3772
Practice Address - Fax:718-255-1841
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2079272084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02104103Medicaid
NYH24677Medicare UPIN
NY02104103Medicaid