Healthcare Provider Details

I. General information

NPI: 1922196948
Provider Name (Legal Business Name): NICHOLAS ROGU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

646 COMMACK RD R.B.K PEDIATRICS
COMMACK NY
11725-5404
US

IV. Provider business mailing address

56 OLD BROOK ROAD
DIX HILLS NY
11746-6432
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-4114
  • Fax: 631-499-1468
Mailing address:
  • Phone: 631-940-2960
  • Fax: 631-666-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number233227
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier02201256
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier00401381
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerGROUP MA #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: