1619968161 NPI number — DR. JOHN L KEFALOS M.D.

Table of content: (NPI 1154329076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619968161 NPI number — DR. JOHN L KEFALOS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEFALOS
Provider First Name:
JOHN
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1619968161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 SUNRISE HWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LYNBROOK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11563-2950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-887-3516
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 SUNRISE HWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LYNBROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11563-2950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-887-3516
Provider Business Practice Location Address Fax Number:
516-887-0331
Provider Enumeration Date:
11/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  152638 , 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: 152638 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 62259790 . This is a "MULTIPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 640026 . This is a "HEALTHCARE PARTNERS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AS1069 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 112573413 . This is a "CCN,CHO HUM,FRSTHELTH,HOR" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 68866 . This is a "PHCS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AD00676 . This is a "MDNY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01572861 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: NS0001847 . This is a "SELECT PRO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1917532005 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: OC3470 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: CPNN1526383 . This is a "WORKERS COMP NO FAULT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 112573413 . This is a "MAG,OHP,UHC,EMPIRE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3099813 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000056378 . This is a "GHI HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 613 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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