Basic Information
| Provider Information | |||||||||
| NPI: | 1538500020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTILLO | ||||||||
| FirstName: | MIGUEL | ||||||||
| MiddleName: | ANGEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTILLO CORREA | ||||||||
| OtherFirstName: | MIGUEL ANGEL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1468 MADISON AVE RM 378 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122418867 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1111 AMSTERDAM AVE | ||||||||
| Address2: | PLANT BUILDING, SUITE 2050 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100251716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125232589 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 293031 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 2086S0102X | 293031 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
No ID Information.