Healthcare Provider Details

I. General information

NPI: 1649403874
Provider Name (Legal Business Name): MARIANNE W TATEOSIAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIANNE W GOBRIAL D.O.

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 COMMACK RD STE 105
COMMACK NY
11725-5020
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-632-9510
  • Fax: 631-216-8319
Mailing address:
  • Phone: 631-444-0650
  • Fax: 631-638-4170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number68136
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number268594-1
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: