Provider Demographics
NPI:1609958321
Name:CABRERA, DEMETRIO C (PT)
Entity Type:Individual
Prefix:MR
First Name:DEMETRIO
Middle Name:C
Last Name:CABRERA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 ORCHID DR
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-5002
Mailing Address - Country:US
Mailing Address - Phone:631-666-4600
Mailing Address - Fax:631-666-4605
Practice Address - Street 1:1766 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6010
Practice Address - Country:US
Practice Address - Phone:631-666-4600
Practice Address - Fax:631-666-4605
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022429-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2582658Medicaid
NY2582658Medicaid