Provider Demographics
NPI:1104092493
Name:PATRYLO, IRENE DIANA (MD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:DIANA
Last Name:PATRYLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BELLE TERRE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1928
Mailing Address - Country:US
Mailing Address - Phone:631-474-6879
Mailing Address - Fax:631-474-6448
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1928
Practice Address - Country:US
Practice Address - Phone:631-474-6879
Practice Address - Fax:631-474-6448
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198926225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner