Provider Demographics
NPI:1437140761
Name:HERRERA-ACEVEDO, LUIS OSCAR (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:OSCAR
Last Name:HERRERA-ACEVEDO
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 1:857 CLIFFSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3001
Mailing Address - Country:US
Mailing Address - Phone:516-791-5919
Mailing Address - Fax:516-223-7320
Practice Address - Street 1:43 CHURCH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3830
Practice Address - Country:US
Practice Address - Phone:516-223-2900
Practice Address - Fax:516-223-7320
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196850208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01513620046Medicaid
F96162Medicare UPIN
NY01513620046Medicaid