Provider Demographics
NPI:1174528723
Name:ABENAVOLI, TANCREDI JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:TANCREDI
Middle Name:JOSEPH
Last Name:ABENAVOLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-2805
Mailing Address - Country:US
Mailing Address - Phone:914-939-1573
Mailing Address - Fax:914-939-2696
Practice Address - Street 1:446 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-2805
Practice Address - Country:US
Practice Address - Phone:914-939-1573
Practice Address - Fax:914-939-2696
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-19
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00585039Medicaid
NY47A661Medicare PIN
B14972Medicare UPIN