Provider Demographics
NPI:1699054916
Name:NUNEZ, KATIUSCHKA (MD)
Entity type:Individual
Prefix:DR
First Name:KATIUSCHKA
Middle Name:
Last Name:NUNEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:KATI
Other - Middle Name:
Other - Last Name:WILLOUGHBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4 BREWSTER CT
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1424
Mailing Address - Country:US
Mailing Address - Phone:631-751-0619
Mailing Address - Fax:631-751-0619
Practice Address - Street 1:4 BREWSTER CT
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1424
Practice Address - Country:US
Practice Address - Phone:631-751-0619
Practice Address - Fax:631-751-0619
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2019-11-13
Deactivation Date:2016-08-10
Deactivation Code:
Reactivation Date:2019-11-13
Provider Licenses
StateLicense IDTaxonomies
NY190780-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine