Provider Demographics
NPI:1952537516
Name:CORDERO, MICHAEL BERTY (RN)
Entity Type:Individual
Prefix:
First Name:MICHAEL BERTY
Middle Name:
Last Name:CORDERO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:CORDERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:194 MONTAUK HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968
Mailing Address - Country:US
Mailing Address - Phone:646-465-0480
Mailing Address - Fax:
Practice Address - Street 1:194 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-4107
Practice Address - Country:US
Practice Address - Phone:646-465-0480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY604756163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse