Provider Demographics
NPI:1679847008
Name:URANTIA MEDICAL PC
Entity Type:Organization
Organization Name:URANTIA MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:MODESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-365-4040
Mailing Address - Street 1:1295 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3035
Mailing Address - Country:US
Mailing Address - Phone:516-365-4040
Mailing Address - Fax:
Practice Address - Street 1:1295 NORTHERN BLVD
Practice Address - Street 2:SUITE 20
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3035
Practice Address - Country:US
Practice Address - Phone:516-365-4040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1818101174400000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01583586Medicaid
NYG39665Medicare UPIN