1083632905 NPI number — DR. DENNIS LYLE DRAIZIN MD

Table of content: DR. DENNIS LYLE DRAIZIN MD (NPI 1083632905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083632905 NPI number — DR. DENNIS LYLE DRAIZIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRAIZIN
Provider First Name:
DENNIS
Provider Middle Name:
LYLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1083632905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
195 N VILLAGE AVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
ROCKVILLE CENTRE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11570-3814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-536-7777
Provider Business Mailing Address Fax Number:
516-536-9225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 N VILLAGE AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
ROCKVILLE CENTRE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11570-3814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-536-7777
Provider Business Practice Location Address Fax Number:
516-536-9225
Provider Enumeration Date:
07/18/2006

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: 207Y00000X , with the licence number:  134130 , 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: 00774956 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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