Healthcare Provider Details

I. General information

NPI: 1497702617
Provider Name (Legal Business Name): COMMACK COMPREHENSIVE PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 COMMACK RD SUITE 325
COMMACK NY
11725-6021
US

IV. Provider business mailing address

2171 JERICHO TPKE SUITE 342
COMMACK NY
11725-2937
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-3588
  • Fax: 631-499-3583
Mailing address:
  • Phone: 631-499-3588
  • Fax: 631-499-3583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number188094
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01600215
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: DR. BRITTA KAREEN MAZUR
Title or Position: PEDIATRICIAN
Credential: DO
Phone: 631-499-3588