Provider Demographics
NPI:1104975796
Name:PEDIATRIC FAMILY MDPC
Entity type:Organization
Organization Name:PEDIATRIC FAMILY MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:VALENCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-779-5855
Mailing Address - Street 1:3230 156TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-3326
Mailing Address - Country:US
Mailing Address - Phone:718-779-5855
Mailing Address - Fax:718-779-1053
Practice Address - Street 1:3752 82ND ST
Practice Address - Street 2:2ND FL.
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7032
Practice Address - Country:US
Practice Address - Phone:718-779-5855
Practice Address - Fax:718-779-1053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01515008Medicaid