Provider Demographics
NPI:1124139035
Name:PASSIDOMO, CHRISTOPHER DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:PASSIDOMO
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 1:152 SYCAMORE CIR
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3161
Mailing Address - Country:US
Mailing Address - Phone:631-941-0018
Mailing Address - Fax:631-941-0018
Practice Address - Street 1:213 HALLOCK RD
Practice Address - Street 2:SUITE 3A
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3000
Practice Address - Country:US
Practice Address - Phone:631-689-3771
Practice Address - Fax:631-689-1131
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2138182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01955848Medicaid
NY213818OtherNEW YORK STATE LICENSE
NY213818OtherNEW YORK STATE LICENSE
NYBP6285274OtherDEA NUMBER
NY7Y8201Medicare ID - Type UnspecifiedMEDICARE ID NUMBER