Provider Demographics
NPI:1770678005
Name:TANAEL, LORETO VERGARA (MD)
Entity Type:Individual
Prefix:
First Name:LORETO
Middle Name:VERGARA
Last Name:TANAEL
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 1:233 NOSTRAND AVE
Mailing Address - Street 2:ATTENTION CELESTE JACKSON
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205
Mailing Address - Country:US
Mailing Address - Phone:718-826-3911
Mailing Address - Fax:718-826-3860
Practice Address - Street 1:3245 NOSTRAND AVE
Practice Address - Street 2:KINGS HWY CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:718-615-3777
Practice Address - Fax:718-615-3481
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1138351208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY955201Medicare ID - Type Unspecified
B20380Medicare UPIN