Healthcare Provider Details

I. General information

NPI: 1134116387
Provider Name (Legal Business Name): ANNETTE F RACANIELLO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ANDIRON LN
BROOKHAVEN NY
11719-0078
US

IV. Provider business mailing address

PO BOX 78
BROOKHAVEN NY
11719-0078
US

V. Phone/Fax

Practice location:
  • Phone: 631-286-2355
  • Fax: 631-286-6808
Mailing address:
  • Phone: 631-286-2355
  • Fax: 631-286-6808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number157578
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: