Provider Demographics
NPI:1083632905
Name:DRAIZIN, DENNIS LYLE (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:LYLE
Last Name:DRAIZIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 N VILLAGE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3814
Mailing Address - Country:US
Mailing Address - Phone:516-536-7777
Mailing Address - Fax:516-536-9225
Practice Address - Street 1:195 N VILLAGE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3814
Practice Address - Country:US
Practice Address - Phone:516-536-7777
Practice Address - Fax:516-536-9225
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134130207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00774956Medicaid
NY00774956Medicaid
NY31A921Medicare ID - Type Unspecified