Provider Demographics
NPI:1427355775
Name:SUFFOLK PEDIATRIC, PC
Entity type:Organization
Organization Name:SUFFOLK PEDIATRIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EFRAIN
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-582-2228
Mailing Address - Street 1:45 W SUFFOLK AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-2156
Mailing Address - Country:US
Mailing Address - Phone:631-582-2228
Mailing Address - Fax:631-582-4881
Practice Address - Street 1:45 W SUFFOLK AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2156
Practice Address - Country:US
Practice Address - Phone:631-582-2228
Practice Address - Fax:631-582-4881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258769-1207Q00000X
NY215692-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI02685Medicare UPIN