Provider Demographics
NPI:1942532791
Name:ECHENIQUE MEDICAL OFFICE PC
Entity Type:Organization
Organization Name:ECHENIQUE MEDICAL OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ECHENIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-762-6640
Mailing Address - Street 1:41-15 162ND STREET
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-4124
Mailing Address - Country:US
Mailing Address - Phone:718-762-6640
Mailing Address - Fax:718-762-6635
Practice Address - Street 1:41-15 162ND STREET
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-4124
Practice Address - Country:US
Practice Address - Phone:718-762-6640
Practice Address - Fax:718-762-6635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212182207R00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05095OtherMEDICARE ID#
NY02457472Medicaid
NY02457472Medicaid