Provider Demographics
NPI:1285264192
Name:DEER PARK MEDICAL, P.C.
Entity type:Organization
Organization Name:DEER PARK MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROBERTO
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-302-5700
Mailing Address - Street 1:2103 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-1317
Mailing Address - Country:US
Mailing Address - Phone:631-302-5700
Mailing Address - Fax:631-918-5724
Practice Address - Street 1:2103 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-1317
Practice Address - Country:US
Practice Address - Phone:631-302-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty