Provider Demographics
NPI:1932125457
Name:LONG BEACH VASCULAR GEN SUR
Entity Type:Organization
Organization Name:LONG BEACH VASCULAR GEN SUR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPIETER
Authorized Official - Prefix:
Authorized Official - First Name:NEYSA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTIN-CAPELES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-432-1094
Mailing Address - Street 1:711 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-2315
Mailing Address - Country:US
Mailing Address - Phone:516-432-1094
Mailing Address - Fax:516-432-1095
Practice Address - Street 1:711 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2315
Practice Address - Country:US
Practice Address - Phone:516-432-1094
Practice Address - Fax:516-432-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202814174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02076117Medicaid
NY02076117Medicaid
06124Medicare PIN
NYWEP971Medicare ID - Type Unspecified