Basic Information
| Provider Information | |||||||||
| NPI: | 1154749521 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELLOMO | ||||||||
| FirstName: | LEA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | PURCHASE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105772547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9148488840 | ||||||||
| FaxNumber: | 9148488629 | ||||||||
| Practice Location | |||||||||
| Address1: | 73 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9148488840 | ||||||||
| FaxNumber: | 9148488629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 09/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 293604 | NY | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 05210999 | 05 | NY | MEDICAID |