Provider Demographics
NPI:1841263274
Name:MITROMARAS, ANTOUN SABA (MD)
Entity type:Individual
Prefix:DR
First Name:ANTOUN
Middle Name:SABA
Last Name:MITROMARAS
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 1:509 PATCHOGUE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1006
Mailing Address - Country:US
Mailing Address - Phone:631-331-1100
Mailing Address - Fax:631-331-0223
Practice Address - Street 1:509 ROUTE 112
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-331-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF40969Medicare UPIN
NY36L571Medicare ID - Type Unspecified