Basic Information
| Provider Information | |||||||||
| NPI: | 1598963134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELFON-KORNYOH | ||||||||
| FirstName: | LATRICE | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 819 S SALINA ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132023527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
| FaxNumber: | 3154751448 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 S SALINA ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132023527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
| FaxNumber: | 3154751448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | 244245 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 208000000X | 244245 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1214298 | 01 | IHA | OTHER | 000529533001 | 01 | BC/BS | OTHER | 02911755 | 05 | NY | MEDICAID | 071121000069 | 01 | FIDELIS | OTHER |