Provider Demographics
NPI:1750936571
Name:QUINTEROS, MARIVXY
Entity type:Individual
Prefix:
First Name:MARIVXY
Middle Name:
Last Name:QUINTEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 EAST 175TH STREER
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2536
Mailing Address - Country:US
Mailing Address - Phone:718-960-7522
Mailing Address - Fax:718-583-6439
Practice Address - Street 1:966 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-3270
Practice Address - Country:US
Practice Address - Phone:718-842-1412
Practice Address - Fax:718-947-2257
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF406190363LP0808X
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY08131064Medicaid