1396067591 NPI number — ANTHONY N. DONATELLI JR MD., PC

Table of content: (NPI 1396067591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396067591 NPI number — ANTHONY N. DONATELLI JR MD., PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTHONY N. DONATELLI JR MD., PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396067591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 406
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKHAVEN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11719-0406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-730-0406
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 HOSPITAL RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
EAST PATCHOGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11772-8809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-730-0406
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DONATELLI
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
631-730-0406

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  167827 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 167827 . This is a "LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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