Healthcare Provider Details

I. General information

NPI: 1407021850
Provider Name (Legal Business Name): BRIAN J BEZACK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 COMMACK RD SUITE 100
COMMACK NY
11725-3405
US

IV. Provider business mailing address

66 COMMACK RD SUITE 100
COMMACK NY
11725-3405
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-1298
  • Fax: 631-499-1700
Mailing address:
  • Phone: 631-499-1298
  • Fax: 631-499-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number251674
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number251674
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: