Provider Demographics
NPI:1619908639
Name:MALDONADO, LUIS V (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:V
Last Name:MALDONADO
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 1:1100 SHAMES DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1765
Mailing Address - Country:US
Mailing Address - Phone:516-693-0700
Mailing Address - Fax:
Practice Address - Street 1:42 FLEETWOOD RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-1760
Practice Address - Country:US
Practice Address - Phone:631-209-9430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199111-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01592209Medicaid
NY43I451Medicare PIN
NYF73826Medicare UPIN