Healthcare Provider Details

I. General information

NPI: 1205894268
Provider Name (Legal Business Name): AVI SAMSON RETTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 EASTCHESTER RD
BRONX NY
10469-5930
US

IV. Provider business mailing address

1500 ROUTE 112 BLDG 4
PORT JEFFERSON STATION NY
11776-8055
US

V. Phone/Fax

Practice location:
  • Phone: 718-732-4000
  • Fax:
Mailing address:
  • Phone: 631-751-3000
  • Fax: 631-509-6559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number235196-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: