Basic Information
| Provider Information | |||||||||
| NPI: | 1568966562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RONDEROS | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RONDEROS | ||||||||
| OtherFirstName: | DIANA | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 627 SHALER BLVD APT A | ||||||||
| Address2: | |||||||||
| City: | RIDGEFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076573728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016572731 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1650 GRAND CONCOURSE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104577697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189601234 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2018 | ||||||||
| LastUpdateDate: | 03/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.