Basic Information
| Provider Information | |||||||||
| NPI: | 1962442780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CERVANTES | ||||||||
| FirstName: | LOBER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10850 62ND DR | ||||||||
| Address2: | STE LA | ||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113758420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188968000 | ||||||||
| FaxNumber: | 7182067169 | ||||||||
| Practice Location | |||||||||
| Address1: | 10850 62ND DR | ||||||||
| Address2: | STE LA | ||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113758420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188968000 | ||||||||
| FaxNumber: | 7188968009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 234737 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2646399 | 05 | NY | MEDICAID |