Provider Demographics
NPI:1336397686
Name:J. R. UDARBE MD P.C.
Entity Type:Organization
Organization Name:J. R. UDARBE MD P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTENDING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:UDARBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-336-2560
Mailing Address - Street 1:1010 NORTHERN BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5306
Mailing Address - Country:US
Mailing Address - Phone:516-336-2560
Mailing Address - Fax:516-336-2561
Practice Address - Street 1:1010 NORTHERN BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5306
Practice Address - Country:US
Practice Address - Phone:516-336-2560
Practice Address - Fax:516-336-2561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208198261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG78238Medicare UPIN