Basic Information
Provider Information | |||||||||
NPI: | 1790914026 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALCANTARA CONTRERAS | ||||||||
FirstName: | JOSE | ||||||||
MiddleName: | ANGEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ALCANTARA | ||||||||
OtherFirstName: | JOSE | ||||||||
OtherMiddleName: | ANGEL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1425 PORTLAND AVE | ||||||||
Address2: | RGH DEPT. OF MEDICINE, 5TH FLOOR | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146213001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5859225067 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1425 PORTLAND AVE | ||||||||
Address2: | RGH DEPT. OF MEDICINE, 5TH FLOOR | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 14621 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5859225067 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2009 | ||||||||
LastUpdateDate: | 12/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 004054 | NY | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 004054 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 03478017 | 05 | NY |   | MEDICAID |