Provider Demographics
NPI:1760455497
Name:LLANOS, EVELYN (MD)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:LLANOS
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 SOUTHDOWN RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-470-2572
Mailing Address - Fax:631-385-1748
Practice Address - Street 1:19 SOUTHDOWN RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2538
Practice Address - Country:US
Practice Address - Phone:631-470-2572
Practice Address - Fax:631-423-9276
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-10-04
Deactivation Date:2007-10-10
Deactivation Code:
Reactivation Date:2007-10-24
Provider Licenses
StateLicense IDTaxonomies
NY2381051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02729913Medicaid
NY3413P1Medicare PIN
NY02729913Medicaid
I48744Medicare UPIN
NYW9FF41Medicare PIN