| NPI | 1477629400 |
|---|---|
| Former Legal Business Name | 496 NESCONSET HWY SUITE 200 SMITHTOWN NY 11787 |
| Entity Type | Organization |
| Authorized Contact | AUGUSTUS MANTIA Md 631-265-9111 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 182606) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: NY 094617) |
| 207R00000X Internal Medicine (Licence: NY 124142) | |
| Enumeration Date | 2006-11-28 |
| Last Update Date | 2020-08-22 |