Provider Demographics
NPI:1205125820
Name:LANTIGUA-TATEM, LUIS NELSON ROMAN (MD)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:NELSON ROMAN
Last Name:LANTIGUA-TATEM
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 1:1650 SELWYN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7626
Mailing Address - Country:US
Mailing Address - Phone:718-316-1702
Mailing Address - Fax:
Practice Address - Street 1:1770 GRAND CONCOURSE
Practice Address - Street 2:APT A-C
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-5524
Practice Address - Country:US
Practice Address - Phone:347-304-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0010882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine