Provider Demographics
NPI:1558445494
Name:FIORDALISI, JOHN J (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:FIORDALISI
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 1:35 HAMPTON BAYS DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-3007
Mailing Address - Country:US
Mailing Address - Phone:631-723-0622
Mailing Address - Fax:
Practice Address - Street 1:2800 MARCUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1008
Practice Address - Country:US
Practice Address - Phone:516-622-6131
Practice Address - Fax:516-622-7401
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1692381207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
45F35ZT2E1OtherMEDICARE PIN/TPAN
NY299T01OtherBC/BS
45F35ZT2E1OtherMEDICARE PIN/TPAN