Basic Information
| Provider Information | |||||||||
| NPI: | 1730410663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASUPANG | ||||||||
| FirstName: | SEDRIC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10509 JAMAICA AVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184413211 | ||||||||
| FaxNumber: | 7184413744 | ||||||||
| Practice Location | |||||||||
| Address1: | 10509 JAMAICA AVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184413211 | ||||||||
| FaxNumber: | 7184413744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2010 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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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 | 174400000X | 031206-1 | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 031206-1 | 01 | NY | LICENSE NUMBER | OTHER |