Provider Demographics
NPI:1699711929
Name:YAMBO, EDWARDO MARTH (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARDO
Middle Name:MARTH
Last Name:YAMBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 EAST INDUSTRY CT
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729
Mailing Address - Country:US
Mailing Address - Phone:631-667-0222
Mailing Address - Fax:631-667-0223
Practice Address - Street 1:60 E INDUSTRY CT
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-4728
Practice Address - Country:US
Practice Address - Phone:631-667-0222
Practice Address - Fax:631-667-0223
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00635612Medicaid
NY00635612Medicaid
B01423Medicare UPIN