1760593867 NPI number — DR. BEN R DIMICHINO DPM

Table of content: DR. BEN R DIMICHINO DPM (NPI 1760593867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760593867 NPI number — DR. BEN R DIMICHINO DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIMICHINO
Provider First Name:
BEN
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1760593867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 SHORE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST SETAUKET
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11733-3920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-689-0202
Provider Business Mailing Address Fax Number:
631-689-2686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 SHORE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST SETAUKET
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11733-3920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-689-0202
Provider Business Practice Location Address Fax Number:
631-689-2686
Provider Enumeration Date:
08/31/2006

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: 213E00000X , with the licence number:  N004656 , 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: 114212 . This is a "VYTRA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 792279 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01590385 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P2545365 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA47838 . This is a "MDNY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4450726 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1C1330 . This is a "HEALTH NET" identifier . This identifiers is of the category "OTHER".




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