Provider Demographics
NPI:1154432102
Name:LEFFERTS MEDICAL PRACTICE, LLC
Entity type:Organization
Organization Name:LEFFERTS MEDICAL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-205-4911
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-0270
Mailing Address - Country:US
Mailing Address - Phone:531-264-2035
Mailing Address - Fax:631-264-1418
Practice Address - Street 1:9001A ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7938
Practice Address - Country:US
Practice Address - Phone:718-205-4911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07615Medicare PIN