Basic Information
| Provider Information | |||||||||
| NPI: | 1033327556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAEZ SOCORRO | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUSTAVE L LEVY PL | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296504 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 GUSTAVE L LEVY PL | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | 35-093410 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 390200000X | MT187895 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2080P0206X | 1917669 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0067920 | 05 | OH | MEDICAID |