1730604752 NPI number — DANIEL THOMAS IPPOLITO ANP

Table of content: DANIEL THOMAS IPPOLITO ANP (NPI 1730604752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730604752 NPI number — DANIEL THOMAS IPPOLITO ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IPPOLITO
Provider First Name:
DANIEL
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
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:
1730604752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
712 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISLIP
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11751-3620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-666-3951
Provider Business Mailing Address Fax Number:
631-750-1177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 MEDFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PATCHOGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11772-1281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-666-3951
Provider Business Practice Location Address Fax Number:
631-750-1177
Provider Enumeration Date:
08/10/2017

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: 363LA2200X , with the licence number:  308385 , 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: 308385 . This is a "NYS OFFICE OF PROFESSIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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