Basic Information
| Provider Information | |||||||||
| NPI: | 1518258391 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VISTA MEDICAL SERVICES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1990 LEXINGTON AVE | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100352902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124104400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26 FIREMENS MEMORIAL DR STE 115 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109703569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453628400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 04/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | COBURN | ||||||||
| AuthorizedOfficialFirstName: | E. LANCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2124104400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 198832 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.