Basic Information
| Provider Information | |||||||||
| NPI: | 1962665737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELGUERO | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | LUCIEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 391 MYRTLE AVENUE | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182072273 | ||||||||
| FaxNumber: | 5182072293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 249373 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35.096829 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02986249 | 05 | NY | MEDICAID | 3153215 | 05 | OH | MEDICAID |