Healthcare Provider Details

I. General information

NPI: 1427495068
Provider Name (Legal Business Name): BRIAN BEZACK DO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6080 JERICHO TPKE SUITE 318
COMMACK NY
11725-2850
US

IV. Provider business mailing address

6080 JERICHO TPKE SUITE 318
COMMACK NY
11725-2850
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-1298
  • Fax: 631-486-6712
Mailing address:
  • Phone: 631-499-1298
  • Fax: 631-486-6712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number215674
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name: BRIAN BEZACK
Title or Position: PRESIDENT
Credential: D.O.
Phone: 631-499-1298