1275576787 NPI number — LYONEL DE SAGUN

Table of content: LYONEL DE SAGUN (NPI 1275576787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275576787 NPI number — LYONEL DE SAGUN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE SAGUN
Provider First Name:
LYONEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DE SAGUN
Provider Other First Name:
LYONEL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1275576787
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:
10 E 16TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON STATION
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11746-2911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-816-9696
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1979 MARCUS AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
LAKE SUCCESS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11042-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-327-4681
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2006

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: 225100000X , with the licence number:  019091 , 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: 019091 . This is a "PT LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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