Provider Demographics
NPI:1215167390
Name:SCOMA, MICHAEL ROBERT (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:SCOMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:173 MINEOLA BLVD
Mailing Address - Street 2:SUITE 401A
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2528
Mailing Address - Country:US
Mailing Address - Phone:516-746-2212
Mailing Address - Fax:516-746-3231
Practice Address - Street 1:173 MINEOLA BLVD
Practice Address - Street 2:SUITE 401A
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2528
Practice Address - Country:US
Practice Address - Phone:516-746-2212
Practice Address - Fax:516-746-3231
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257035207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03281761Medicaid
NYA300031858Medicare PIN