Healthcare Provider Details

I. General information

NPI: 1073441770
Provider Name (Legal Business Name): ADDLER JOSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 VANDERBILT AVE
CENTRAL ISLIP NY
11722-1106
US

IV. Provider business mailing address

53 VANDERBILT AVE
CENTRAL ISLIP NY
11722-1106
US

V. Phone/Fax

Practice location:
  • Phone: 862-755-9951
  • Fax:
Mailing address:
  • Phone: 862-755-9951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number356034
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: