Healthcare Provider Details

I. General information

NPI: 1649254004
Provider Name (Legal Business Name): DOUGLAS R PHILLIPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 E MAIN ST
BAY SHORE NY
11706-8418
US

IV. Provider business mailing address

375 E MAIN ST
BAY SHORE NY
11706-8418
US

V. Phone/Fax

Practice location:
  • Phone: 631-646-1001
  • Fax: 631-646-9803
Mailing address:
  • Phone: 631-646-1001
  • Fax: 631-646-9803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number130753
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: