1689640690 NPI number — DR. DAMIAN FORLETTI M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689640690 NPI number — DR. DAMIAN FORLETTI M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

FORLETTI

Provider First Name:

DAMIAN

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1689640690

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

09/19/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 1559

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

STONY BROOK

Provider Business Mailing Address State Name:

NY

Provider Business Mailing Address Postal Code:

11790

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

815 HALLOCK AVE

Provider Second Line Business Practice Location Address:

SUITE A

Provider Business Practice Location Address City Name:

PORT JEFFERSON STATION

Provider Business Practice Location Address State Name:

NY

Provider Business Practice Location Address Postal Code:

11776-1244

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

631-331-7267

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

02/28/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208000000X , with the licence number:  164113 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 877643 . This is a "AETNA HMO ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: OC9245 . This is a "PHS / HEALTH NET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 164113 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: CP103 . This is a "OXFORD ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 2787 . This is a "VYTRA ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 4061141 . This is a "AETNA NON-HMO ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 2600579 . This is a "GHI PPO ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 1807144003 . This is a "CIGNA ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 5B780 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 000000059056 . This is a "GHI HMO ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 01082773 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
• Identifier: O85640 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".