Healthcare Provider Details

I. General information

NPI: 1700020260
Provider Name (Legal Business Name): ANNETTE RACANIELLO D O P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ANDIRON LN
BROOKHAVEN NY
11719-9534
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: MRS. NANCY RACANIELLO
Title or Position: OFFICE MANAGER
Credential:
Phone: 631-286-2355