Provider Demographics
NPI:1023638012
Name:SPORTS MEDICINE SPECIALIST P.C.
Entity type:Organization
Organization Name:SPORTS MEDICINE SPECIALIST P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROMULO
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-418-6618
Mailing Address - Street 1:3235 83RD ST
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-2007
Mailing Address - Country:US
Mailing Address - Phone:347-418-6618
Mailing Address - Fax:
Practice Address - Street 1:1578 WILLIAMSBRIDGE RD # 3D
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-6265
Practice Address - Country:US
Practice Address - Phone:347-418-6618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty