Basic Information
| Provider Information | |||||||||
| NPI: | 1093771206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THEOGENE | ||||||||
| FirstName: | FERNAND | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 592 ROCKAWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112125539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183455000 | ||||||||
| FaxNumber: | 7183455794 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 ASHFORD ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112077315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183455000 | ||||||||
| FaxNumber: | 7183455794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 07/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 196985 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01847281 | 05 | NY | MEDICAID |