Provider Demographics
NPI:1063795276
Name:TEODORO MARIANO JR MD PC
Entity type:Organization
Organization Name:TEODORO MARIANO JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TEODORO
Authorized Official - Middle Name:REYES
Authorized Official - Last Name:MARIANO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:585-352-4411
Mailing Address - Street 1:21 UNION HILL DR
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-1965
Mailing Address - Country:US
Mailing Address - Phone:585-352-4411
Mailing Address - Fax:585-352-1305
Practice Address - Street 1:21 UNION HILL DR
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1965
Practice Address - Country:US
Practice Address - Phone:585-352-4411
Practice Address - Fax:585-352-1305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129789207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00487921Medicaid
C49023Medicare UPIN