Basic Information
| Provider Information | |||||||||
| NPI: | 1619928868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADRID | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PORT WASHINGTON BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ROSLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115761353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163909640 | ||||||||
| FaxNumber: | 5163909650 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PORT WASHINGTON BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ROSLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115761353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163909640 | ||||||||
| FaxNumber: | 5163909650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 207914 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 207914 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 02599200 | 05 | NY | MEDICAID |