Basic Information
| Provider Information | |||||||||
| NPI: | 1497740807 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROSPERE | ||||||||
| FirstName: | EVERTON | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 CLARKSON AVE | ||||||||
| Address2: | BOX 59 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182708867 | ||||||||
| FaxNumber: | 7182701794 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 CLARKSON AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182701531 | ||||||||
| FaxNumber: | 7182701561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 04/17/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 226783-1 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02367173 | 05 | NY | MEDICAID |