Basic Information
| Provider Information | |||||||||
| NPI: | 1760455497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LLANOS | ||||||||
| FirstName: | EVELYN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 SOUTHDOWN RD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314702572 | ||||||||
| FaxNumber: | 6313851748 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 SOUTHDOWN RD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117432538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314702572 | ||||||||
| FaxNumber: | 6314239276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 10/04/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/10/2007 | ||||||||
| NPIReactivationDate: | 10/24/2007 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2381051 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02729913 | 05 | NY | MEDICAID |