Provider Demographics
NPI:1841576840
Name:CASTROVERDE-MALANUM, CECILIA DORONILA (MD)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:DORONILA
Last Name:CASTROVERDE-MALANUM
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 1:52 DIX WOODS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4108
Mailing Address - Country:US
Mailing Address - Phone:631-491-3210
Mailing Address - Fax:631-491-3210
Practice Address - Street 1:52 DIX WOODS DRIVE
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4108
Practice Address - Country:US
Practice Address - Phone:631-491-3210
Practice Address - Fax:631-491-3210
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117362207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01558887Medicaid
NY01558887Medicaid