Provider Demographics
NPI:1407247240
Name:AFFENITA, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:AFFENITA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 SILLS RD
Mailing Address - Street 2:BLDG 3 SUITE D
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4869
Mailing Address - Country:US
Mailing Address - Phone:631-438-1075
Mailing Address - Fax:877-366-5492
Practice Address - Street 1:8333 W MCNAB RD
Practice Address - Street 2:STE 228
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-3242
Practice Address - Country:US
Practice Address - Phone:877-776-8400
Practice Address - Fax:877-366-5492
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR 160222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0445310001Medicare NSC