Provider Demographics
NPI:1801987417
Name:AMBEGUIA, RENATO F (PT)
Entity type:Individual
Prefix:
First Name:RENATO
Middle Name:F
Last Name:AMBEGUIA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 PALM LN
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-6311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6035 FRESH POND RD
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-3541
Practice Address - Country:US
Practice Address - Phone:718-628-5326
Practice Address - Fax:718-628-3719
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019974-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
08328IMedicare PIN