Facts
- Status
- A
- Credential
- NP
- Type
- Individual
- Enumeration date
- 2007-05-17
- Last updated
- 2013-11-25
Licenses
- License NY
- 428863
- License NY
- F305252
Location
- Practice location
- 309 LENA AVENUE
- City
- FREEPORT NY
- Postal code
- 11520
- Phone
- 516-662-3979
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.