Healthcare Provider Details

I. General information

NPI: 1982071619
Provider Name (Legal Business Name): MJL MEDICAL HEALTHCARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HOWELLS RD
BAY SHORE NY
11706-5351
US

IV. Provider business mailing address

200 HOWELLS RD
BAY SHORE NY
11706-5351
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-1439
  • Fax: 631-665-1383
Mailing address:
  • Phone: 631-665-1439
  • Fax: 631-665-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number171063
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number171063
License Number StateNY

VIII. Authorized Official

Name: DR. MARK JOSEPH LODESPOTO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 631-665-1439