Provider Demographics
NPI:1821660614
Name:FERNANDES DE PAULA TITO JORGE, MARIA CLARA
Entity Type:Individual
Prefix:
First Name:MARIA CLARA
Middle Name:
Last Name:FERNANDES DE PAULA TITO JORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA CLARA
Other - Middle Name:
Other - Last Name:FERNANDES DE PAULA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:303 E 60TH ST APT 23E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1523
Mailing Address - Country:US
Mailing Address - Phone:646-531-6687
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP1051142085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging