Provider Demographics
NPI:1174338552
Name:PERONILLA, JESUBIELIN CUSTODIO (PT)
Entity type:Individual
Prefix:MR
First Name:JESUBIELIN
Middle Name:CUSTODIO
Last Name:PERONILLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 23RD AVE APT 1F
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1963
Mailing Address - Country:US
Mailing Address - Phone:347-350-1235
Mailing Address - Fax:
Practice Address - Street 1:3808 23RD AVE APT 1F
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-1963
Practice Address - Country:US
Practice Address - Phone:347-350-1235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050395208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation