Provider Demographics
NPI:1609899335
Name:MONTECALVO, MARISA A (MD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:A
Last Name:MONTECALVO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BRADHURST AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2140
Mailing Address - Country:US
Mailing Address - Phone:914-493-8865
Mailing Address - Fax:914-594-2461
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-493-8865
Practice Address - Fax:914-594-2461
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168052207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01213510Medicaid
NY110063293OtherRAILROAD MEDICARE
NY59F5605271Medicare PIN
NY118327OtherWELLCARE
NY4318633OtherAETNA PPO
NY2500991OtherGHI PPO
NY59F563OtherEMPIRE BCBS (NYMC)
NY925999OtherMVP
NYWS464OtherOXFORD
NY01213510Medicaid
NY168052OtherHIP
NY59F561OtherEMPIRE BCBS (VALHALLA)
NY5C6333OtherHEALTHNET