1215032297 NPI number — DAMIAN A MARRESE DO

Table of content: DAMIAN A MARRESE DO (NPI 1215032297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215032297 NPI number — DAMIAN A MARRESE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARRESE
Provider First Name:
DAMIAN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1215032297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2340
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAMPTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11969-2340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-283-2430
Provider Business Mailing Address Fax Number:
631-283-7496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
860 MONTAUK HWY
Provider Second Line Business Practice Location Address:
#247
Provider Business Practice Location Address City Name:
WATER MILL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11976-0247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-726-6073
Provider Business Practice Location Address Fax Number:
631-726-6076
Provider Enumeration Date:
09/14/2006

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: 207Q00000X , with the licence number:  194499 , 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: 57802 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7227893 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7D6021 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01837145 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 219464P . This is a "HIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: P4391206 . This is a "OXF" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1377871 . This is a "UHC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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