Healthcare Provider Details

I. General information

NPI: 1215221858
Provider Name (Legal Business Name): ANTHONY A. PELOSI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 05/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 4TH AVE
BAY SHORE NY
11706-7908
US

IV. Provider business mailing address

22 KNOX AVE
STONY BROOK NY
11790-1538
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-6707
  • Fax: 631-665-3564
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number104072-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: